Pediatric emergency medicine trisk 493

Initial management
Remove from source of current
Cardiopulmonary resuscitation as needed
Provide mechanical ventilation until spontaneous ventilation is adequate
Immobilize neck and spine
Clinical assessment
Neurologic examination (thorough evaluation for possible spinal cord injury)
Peripheral pulses and perfusion and evaluation of the limbs for compartment
syndrome
Oral burns/edema
Chest wall injury
Abdominal distention
Eye or ear trauma
Cutaneous burns or bruises
Laboratory/Imaging determinations
Complete blood cell count
Blood urea nitrogen, creatinine, urinalysis including myoglobin
Electrolytes
Troponin
Electrocardiogram (ECG)
Consider skull, spine, chest, long bone radiographs
Consider computed tomography scan of brain (especially in lightning injuries)
Consider electroencephalogram
Monitoring
Heart rate, ECG, respiratory rate, blood pressure
Management
Maintenance fluids: 5% dextrose in normal saline
Volume expansion in presence of thermal burns or extensive deep tissue injury:
0.9% sodium chloride or lactated Ringer’s solution
Fluid restriction for central nervous system injury
Maintain urine output >1 mL/kg/hr

Treat arrhythmias
Treat seizures
Tetanus toxoid; consider penicillin/other antibiotics
Consider general, oral, or plastic surgical consultation
Cerebral edema may develop over hours to days after injury, especially after a
lightning strike. If the child’s neurologic status fails to improve or deteriorates,
intracranial pressure monitoring and treatment may be necessary. Serum and
urine electrolytes and osmolality should be followed closely to recognize
promptly the syndrome of inappropriate antidiuretic hormone secretion.
Myoglobin in the urine is consistent with muscle breakdown and predisposes to
renal failure. Hydration and brisk diuresis with furosemide and/or mannitol may
prevent renal damage but must be undertaken with caution if there is coexistent
CNS injury. Extensive muscle damage after lightning injury is uncommon,
however, major CNS injury is common. Treatment should proceed with these
relative risks in mind until definitive information is available.
Most burns associated with low-voltage electrical injury are superficial.
Although they may become more apparent after several hours, most remain firstor second-degree burns. Minor burns on the extremities can be treated with
antibiotic ointment and should be allowed to slough and heal. Oral and plastic
surgeons should evaluate children who sustain oral burns. In most cases, similar
conservative management is recommended, but a removable stent may be
necessary to minimize scarring.
High-voltage injuries commonly require aggressive treatment. Fasciotomy may
be necessary to restore adequate circulation to an injured extremity when
compartment syndrome has developed. The approach to debridement of wounds
is controversial, but repeated examinations are considered most useful for
detecting nonviable tissue. Approximately 30% of survivors of high-tension
injuries ultimately require amputation of some part of an extremity.
The risk of infection in patients with deep tissue injury is high. Any patient not

clearly immunized against tetanus should be given tetanus toxoid. Some have
recommended prophylactic antibiotics for oral injuries, but in general,
antimicrobial therapy should be reserved for proven or strongly suspected
infection.

Indications for Discharge and Admission
Any patient who has sustained cardiopulmonary arrest, loss of consciousness, or
deep tissue injury should be admitted to the hospital for evaluation and treatment.


Heart rate, respiratory rate, and BP should be monitored regularly. Doppler
evaluation may be helpful in cases of vasospasm, which may complicate
assessment of BP and subsequent fluid management. True hypotension may
require pressor support and ICU care for treatment of multisystem organ failure.
Electrical or lightning injury in a pregnant woman can pose a risk to the
pregnancy and evaluation by an obstetrician is warranted.

RADIATION INJURIES
Goals of Treatment
The goals of treatment are to decontaminate the patient without contaminating
healthcare providers and to recognize early signs of radiation injury. The
emergency physician should be aware of the basic principles and management of
radiation incidents in order to recognize when it happens, know procedures for
triage and decontamination of victims, alleviate public fears and psychological
trauma about potential incidents, and prevent mismanagement of potential
victims. Frequent training and drills can ensure that the ED staff has the
knowledge, procedural skills, and supplies to deal with possible victims exposed
to radiation accidents.
CLINICAL PEARLS AND PITFALLS
No survivable radiation injury requires direct immediate lifesaving

treatment, hence medical staff should focus their attention on injuryrelated, life-threatening conditions.
The greatest risk of whole-body radiation exposure after 3 to 4 weeks
when bone marrow depression reaches its nadir.
Risk of contamination of ED staff is usually minimal.
Emergency preparedness for radiation injuries is crucial to managing
these incidents and preventing widespread panic among staff and the
public. Understanding and anticipating the number of casualties and
the severity/type of injuries that are most likely to occur is critical for the
emergency provider.

Current Evidence
Types of Radiation


Radiation is a very general term used to describe energy emitted from a source (
Fig. 90.10 ). Ionizing radiation, for example x-ray radiation, deposits a large
amount of energy in a small volume of tissue, and energy is sufficient to strip
electrons from atoms. Nonionizing radiation, for example visible light and
microwave radiation, is less energetic, of longer wavelength, and primarily
deposits heat in tissue.
Ionizing radiation can be further subdivided into types of radiation that have no
associated mass (nonparticulate ) and those that have mass (particulate ). X-rays
and gamma rays are nonparticulate types of radiation and can penetrate deeply
into the body and affect radiation-sensitive tissues, for example, bone marrow and
the lining of the GI tract. X-rays are emitted by excited electrons, whereas gamma
rays are emitted by excited or unstable nuclei (radioisotopes or radionuclides).
Once x-rays or gamma rays have been emitted, they are indistinguishable.
Particulate radiation can be further divided into charged and uncharged
particles. Neutrons, a type of uncharged particulate radiation, can penetrate the
body to depths similar to x-rays and gamma rays. Because neutrons deposit their

energy in a more concentrated area, they cause more biologic damage than x-rays
or gamma rays.