Emergency

Breathing Problems
Parents need to be very aware of the signs of difficult breathing in their children. These signs can be very hard to recognize in infants and young children. As children get older they can describe their difficulty breathing. If your child is too young to describe their difficulty breathing, you can use the Total Parent Breathing Checklist to identify breathing problems in your child. The Checklist uses the word "BREATHING" to help you remember the key points to check:

  • "B"—Breathing Sounds
    Abnormal breath sounds indicate some form of lung problem or airway constriction and include wheezing, a croupy "barking seal cough," congestion, and stridor. Stridor is a high-pitched sound that you can hear when a child breathes in. It sounds as though there is something caught in his airway.
  • "R"—Rate of Breathing
    You should count your child's breathing rate for a full 60 seconds. Keep in mind that one breath in and one breath out count as one breath. What I do is watch the child's chest rise with each breath. I watch for a full minute, counting the number of times the child's chest rises during that time.
  • "E"—Eye Contact and Eating
    If your child is having difficulty breathing, he or she may have trouble focusing on you or other objects. Children who are not getting enough oxygen become anxious. Infants express this with poor eye contact, irritability, and poor feeding.
  • "A"—Appearance and Abdominal Breathing
    What does the child's skin color look like? It is especially important to look at the lips. If a child's lips appear slightly dusky or bluish, that is a sign that he or she is not getting enough oxygen. Is your child's abdomen moving in an exaggerated up and down motion? This is called Abdominal Breathing.
  • "T"—Temperature
    If your child has a rectal temperature of 100.4º F or more, this means he or she has a fever and some type of infection.
  • "H"—Heavy Breathing
    Look carefully to see if your child is having deep and rapid breathing. See if the chest is moving in and out deeper than normal. Also look for the abdominal breathing described above.
  • "I"—Inner Rib Retractions
    A retraction or a "pulling in" of the muscles between the ribs is a sign your child is having difficulty breathing.
  • "N"—Nasal Flaring
    Do the child's nostrils dilate or become wider with each breath? This "nasal flaring" is another sign of labored breathing.
  • "G"—Grunting
    Grunting occurs frequently in children with pneumonia because there is fluid in a portion of their lung. This is a very helpful clue in diagnosing pneumonia and sometimes congestive heart failure in children with congenital heart disease.

Head Injuries
Head injuries can be somewhat challenging to diagnose in children. Some children who have very minimal symptoms are sometimes found to have a blood clot on the brain after some type of head trauma. Other children with head injuries may have some symptoms such as amnesia but have a completely normal CT scan of the brain.

What types of head injuries are the most serious?

  • Head injuries sustained during a motor vehicle accident with loss of consciousness
  • Head injuries associated with symptoms of confusion, amnesia, vomiting, loss of consciousness, double vision, trouble walking, lack of coordination, repeatedly asking the same questions over and over
  • Lacerations or large bruises of the head, which indicate a significant injury
  • Falls in which children fall twice the distance of their height

What is a concussion?
A concussion is a temporary blacking out or loss of consciousness for more than a few seconds. A concussion means that the brain function is temporarily disrupted. Any child who sustains a head injury with a loss of consciousness should be evaluated by your doctor or taken to the emergency room as soon as possible.

If my infant falls off a bed and onto a hard floor, what should I look for?

  • Any signs of bruising to the head
  • Vomiting
  • Excessive sleepiness
  • A change in your child's alertness or ability to focus on objects
  • Persistent fussiness or irritability

If any of the above are present, bring your child immediately to the E.R. or to your doctor's office.

Broken Bones
The most common broken bones or "fractures" in children occur in the ankle, collarbone, elbow, forearm and wrist. If you think your child may have a fracture, it is important to seek medical care right away.

Symptoms

  • Out-of-place or misshapen limb or joint
  • Swelling, bruising or bleeding
  • Intense pain
  • Numbness and tingling
  • Limited mobility or inability to move a limb

Ankle fractures
Ankle sprains usually occur on the outside of the ankle and can range from mild to severe. Severe ankle injuries occur when there is a complete tearing or disruption of the ankle ligaments. Some of these may require surgery but most minor and moderate ankle injuries heal with use of crutches and non-weight bearing. Any ankle injury associated with significant swelling, tenderness and inability to bear weight should be evaluated by a doctor as soon as possible. Significant deformity, such as ankle dislocation, should be evaluated immediately in the emergency room.

Elbow fractures
Elbow fractures are one of the most serious fractures in children. These fractures require very careful orthopedic management and follow up. Whenever a child falls onto their elbow and the elbow is swollen, the parent needs to be concerned about a possible elbow fracture. If a splint is not available, the arm should be carefully supported on a pillow for comfort. The patient should then be brought to the emergency room so that a doctor can take X-rays to determine whether the elbow is broken or dislocated.

Wrist fractures
If the child's wrist is swollen after it is injured, the wrist should be splinted with a small board or placed on a pillow for comfort. The child should then be brought to a doctor or the ER for X-rays to determine whether the wrist is broken or sprained. If there is a fracture that is in good alignment, the doctor will put the wrist in a splint. However, if the fracture has very poor alignment, an orthopedic surgeon may need to correct the fracture.

Choking
Approximately 17,550 children age 14 or younger are treated in U.S. emergency rooms each year for choking. Almost 200 children die in the U.S. each year from choking or airway obstruction. Most of these deaths occur in children younger than four years old. The most common causes of choking deaths are due to hard or firm foods, small toys or other objects on the floor and hard or gooey candies.

What are some of the signs that my child is choking?

  • The child cannot talk or make any age appropriate vocal sounds
  • There is no air movement in and out of the mouth and nose
  • An older child will make the choking sign (holding the neck with one or both hands) and look panicky
  • Persistent and severe coughing or gagging
  • Very difficult breathing
  • Turning blue (especially in the lips)
  • The child suddenly has a hoarse voice

What should I do if my child is choking?
If the child is not speaking, turning blue, not moving air in and out, or has severely labored breathing you must act immediately.

  • Do the Heimlich maneuver, also referred to as "abdominal thrusts" on children older than one year. Continue until the object is coughed up or the child becomes unconscious (limp). If the child becomes unconscious, begin CPR and have someone call the emergency response number.
  • In infants age one year or younger, do 5 back blows followed by 5 chest compressions. Continue until the infant coughs up the object or becomes unconscious (limp). If the infant becomes unconscious, begin CPR and have someone call the emergency response number.

Call 911 or your local emergency number for an ambulance as soon as possible.

Burns
Burns are a frequent occurrence among young children due to their curiosity. Burns usually result from scalding from boiling water in the kitchen and accidental fires.

What are the different types of burns?

  • First-degree burns. First-degree burns are characterized by some redness and pain but no blistering. These are the mildest type of burns.
  • Second-degree burns. Second-degree burns are characterized by redness as well as blistering. The blisters eventually fill with a clear to yellowish fluid and break open. Some second-degree burns may be superficial and heal well. However, some deep second-degree burns may require skin grafting.
  • Third-degree burns. Third-degree burns are the most severe. Third-degree burns cut through all layers of the tissue, and as a result will not heal themselves. These types of burns require skin grafting. They are also characterized by being painless, because the nerve endings have been burned, and as a result the child does not feel pain.

How are burns treated?
Treatment of burns should include simply cooling the area by applying cold water. It is important not to apply any butter, creams, or other non-sterile lotions to the burn area. These may actually increase the chance for infection. A physician needs to get a good look at the burn to see how severe it is.
How can I ease the pain of a burn?
Parents can give their child Tylenol or Motrin as well as a washcloth soaked in cold water to help ease the pain and discomfort.

Bleeding
Small children are often frightened by the sight of their own blood whether they have a minor cut or a serious laceration. Parents can help keep their child (and themselves) calm by knowing some basic steps to caring for and evaluating bleeding wounds.

Basic Care for Minor Cuts

When your child has an abrasion or superficial cut of the hands, feet, arms, or legs:

  • Spray the wound with an antiseptic and numbing spray (if available) to relieve the pain and prevent infection.
  • Wash the wound thoroughly to remove dirt and bacteria.
  • Pat the wound dry, and then apply an antibiotic ointment and a sterile bandage. If the wound continues to bleed, apply pressure until the bleeding stops. When bleeding is severe, it is important to seek medical help immediately.

Evaluating a Serious Laceration
One of the first questions parents have concerning cuts is how to decide which ones require suturing (stitches) and which ones do not. Here are a few general guidelines:

  • Within the first 3-4 hours of a gaping or deep cut to the face, an emergency physician, pediatrician, or family physician should evaluate the cut for the need for stitches.
  • Any lacerations of the hands, feet, or joints should be evaluated within the first 3-4 hours.
  • Puncture wounds of the hands or feet should be evaluated within the first 3-4 hours for thorough wound cleansing and possible antibiotic treatment.
  • Injuries to the scalp should be evaluated early to determine if there is any associated head injury, which may require a CT scan.
  • Any puncture wounds or cuts which may involve a foreign body such as broken glass, metallic objects, or wood splinters should be evaluated within the first 3-4 hours to allow the physician time to explore the wound for the presence of a foreign body.

How often should a child receive a tetanus shot for a cut?
In general, a tetanus shot should be given to a child if the wound is very dirty or contaminated and if the last shot was more than five years ago. However, clean wounds, such as those from a clean glass cup in a kitchen, require a tetanus shot only if more than 10 years have elapsed since the last tetanus shot.

Bites and Stings
Active children are very likely to interact with animals in their play and life explorations. And, not surprisingly, along with good old-fashioned fun sometimes comes the possibility that an injury, like a bite from an animal or insect, may occur. The most common bites come from dogs, cats, spiders, and (unfortunately) even other children.

Dog Bites
Parents need to know that young children do not know how to behave around friendly dogs. Young children may pull their tail because it is moving and it looks like a fun thing to do. Here are a few common sense guidelines for young children near dogs:
All young children should be supervised while they are near dogs. (This includes friendly dogs that are "great with kids.")

  • Dog bites on the hands or feet can cause serious infections.
  • Dog bites on the face can sometimes require plastic surgery.
  • Notify the county animal commissioner about the dog bite and the name or address of the owner, if known. (Emergency rooms do this routinely when someone has an animal bite.)
  • If a dog bite has occurred, the animal commissioner will usually quarantine an unimmunized animal for 10 days and observe it for any signs of rabies.

What is rabies?
Rabies is an infection of the nervous system that causes progressive paralysis, bizarre behavior and even death in untreated cases. Any bites or scratches from infected animals while in foreign countries should be reported to your doctor and the local health department.

Cat Bites
Cat bites usually cause puncture wounds and a high likelihood (50 percent or more) of infection. Most cat bites require thorough cleaning with high-pressure saline in a doctor's office or the emergency department. The child will need to be treated with an antibiotic that is effective against bacteria found in the mouth of cats.

Human Bites
Human bites also tend to become infected. Human bites should be treated with thorough cleansing by a physician in the emergency department along with prescribed antibiotics. Human bites, especially of the fingers or toes, tend to cause more complicated infections.

Spider Bites
Black widow spider bites can cause severe abdominal pain. The bite area looks like a target. Brown recluse spider bites can cause the child to develop a severe deep area of tissue loss over several days.

Stings
If your child is stung by a bee, wash the wound with soap and water. Don't try to remove the stinger with tweezers, instead try to wipe it out using gauze. Next, apply an icepack to minimize swelling. Some children are allergic to bee stings. These reactions can be fatal. Watch your child to see if he or she has swelling that the face, neck or a part of the body that wasn't stung. If your child is having difficulty breathing or feels dizzy, get the child medical attention immediately.

Heat Illnesses
The most common types of heat-related illnesses in children are heat rash, heat cramps, heat exhaustion, and heat stroke. The signs of heat rash include a red rash, usually around areas of the body that are normally covered by clothes—such as the chest or legs. Heat rash is caused by inflammation of the sweat glands.

Heat cramps occur in the larger muscles like the back, thighs, and upper arms after prolonged exercise or working outside.

Heat exhaustion is characterized by weakness, fatigue, lightheadedness, and sometimes headache. Your child may also have an increased temperature of 100 to 101 degrees, but no confusion. If your child has heat exhaustion, place them in a cool environment with cool wet towels around them, and give him or her plenty of fluids.

Heat stroke is a life-threatening medical emergency. Symptoms of heat stroke include confusion, disorientation, a high fever of 103 to 104 degrees and, occasionally, seizures. Heat stroke in children is a life-threatening emergency. If your child suffers from heat stroke, call an ambulance and place your child in a cool environment, apply cool towels and ice packs to the neck, groin, forehead, and sides of the chest, and fan your child until the ambulance arrives.

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