Take these immediate steps for ATV-related trauma

Serious injury may exist even days after an accident

The number of children with injuries from all- terrain vehicle (ATV) accidents has increased dramatically in many EDs. From 1998 to 2004, there was a 100% increase in the number of ATV injuries, which children under 16 representing only 14% of ATV riders, but 33% of injuries and fatalities.1

Of 34 children admitted from the ED at Houston-based Memorial Hermann Children's Hospital, 76% were not wearing helmets, reported a recent study.2

The motivation for the study was a 12-year-old girl who suffered a neck injury after driving into a barbed wire fence during an ATV accident and went into respiratory distress an hour later, says Kevin D. Pereira, MD, one of the study's authors and director of pediatric otolaryngology at the University of Maryland School of Medicine in Baltimore. "She was found to have a complete laryngotracheal separation, which generally results in instant death." The girl subsequently underwent a total laryngectomy and survived.

The ED had seen an increase in ATV accidents in the summer, but information on the lethality of these head and neck injuries in the pediatric age group was scarce, says Pereira. "These factors prompted us to look at the demographics and severity of these injuries in children," he says.

Researchers found that neurocranial injury composed most of the injuries (45%), and soft-tissue injuries to the face also were common (28%). "The implication for ED nurses is to suspect such injuries in every pediatric patient presenting after an ATV accident," says Pereira. "Definitive confirmation of the structural integrity of the airway and central nervous system is a must, irrespective of the patient's outward appearance. Keep every patient NPO until then."

Ask the right questions at triage

Yuma (AZ) Regional Medical Center has seen an increased number of injuries over the last few years, reports Lori Vandersloot, RN, BSN, MBA, CEN, director of emergency services. In 2006, the ED saw 344 ATV injuries, up from 199 the previous year.

ED nurses have noticed that if ATV drivers are riding in sand dunes, they are wearing helmets and occasionally protective gear, but those riding in other off-road areas generally aren't wearing either, notes Vandersloot.

ED nurses at Yuma Regional ask these questions at triage, says Vandersloot:

  • Were you wearing a helmet and protective gear?
  • What was your speed at impact?
  • What distance were you thrown?
  • Did you have loss of consciousness?
  • Do you have any head or neck pain?

Signs that the injury could be life-threatening include the following, says Vandersloot: Skin that is pale, cool, and/or diaphoretic; hypotension or sudden rise in blood pressure; tachycardia or bradycardia; tachypnea; altered level of consciousness; constricted pupils; restlessness; combativeness; and paralysis.

About 75% of children involved in ATV accidents are discharged from Yuma Regional's ED, says Vandersloot. Here are interventions done for children likely to need hospitalization:

  • The child's airway is managed, with possible supplementation with oxygen and/or bag-valve mask/ intubation.
  • Circulation is supported with intravenous fluids and/or blood products.
  • Pain is managed.
  • Diagnostic studies are done, including X-ray, CT scan, and laboratory draws.
  • Cervical spine precautions are taken if there is a potential neck injury.
  • A surgical consult is done as soon as possible if the patient is a potential surgical candidate.

Don't assume injury isn't serious

Twenty-five children were admitted from the ED with ATV injuries at Fort Worth, TX-based Cook Children's Medical Center in 2006, reports Melinda Weaver, RN, trauma quality improvement nurse and former ED nurse.

"Just because a child walks in doesn't mean they don't have a life-threatening injury," she says. "Even if they can walk and talk, they could still have a closed-head injury with intracranial hemorrhage."

If the injured child was not wearing a helmet, ED nurses at Cook take the opportunity to talk to the child and the parents about helmet safety. "We say, 'Now that this happened to you, what would you tell your friends?'" says Weaver. "That is how you get the biggest impact —when someone in their peer group tells them, 'This is what happened to me.' Kids listen to other kids."

Even if a significant amount of time has passed since the accident, don't assume this means the child isn't seriously hurt, says Weaver. "The kid may jump a homemade ramp on Friday night and crash, and here it is Monday and he's complaining of abdominal pain," says Weaver. "The triage nurse may discount it because it's been three days, but the CT comes back and it shows a bleed."

Always have a high index of suspicion if the child has the mechanism of injury and pain, says Weaver. "If the child tells you their stomach's hurting, most nurses will ask about nausea, vomiting, and diarrhea," she says. "But another very important question to ask is, 'Have you had any trauma?' Kids may not tell their parents because they've been someplace they shouldn't have been."

In one case, a teen girl came to Cook Children's ED two days after an ATV accident, and when nurses did the assessment, they found her abdomen was rigid and guarded, says Weaver. "She had a ruptured bowel which could have become septic if care had been delayed any longer," she says.

References

  1. Lingle RL. 2004 Annual report of ATV deaths and injuries. United States Product Safety Commission. September 2005.
  2. Wang BS, Smith SL, Pereira KD. Pediatric head and neck trauma from all-terrain vehicle accidents. Presented at the 110th Annual Meeting of the American Academy of Otolaryngology — Head and Neck Surgery Foundation. Sept. 17-20, 2006. Toronto.

Sources

For more information on caring for children injured from all-terrain vehicle accidents, contact:

  • Kevin D. Pereira, MD, Director of Pediatric Otolaryngology, University of Maryland School of Medicine, 16 S. Eutaw St., Suite 500, Baltimore, MD 21201. Phone: (410) 328- 5828. Fax: (410) 328-5827. E-mail: KPereira@smail.umaryland.edu.
  • Lori Vandersloot, RN, BSN, MBA, CEN, Director, Emergency Services, Yuma Regional Medical Center. 2400 S. Avenue A, Yuma, AZ 85364. Phone: (928) 336-7107. Fax: (928) 336-7705. E-mail: LVandersloot@yumaregional.org.
  • Melinda Weaver, RN, Trauma Quality Improvement Nurse, Cook Children’s Health Care System, 801 Seventh Ave., Fort Worth, TX 76104. Phone: (682) 885-3958. E-mail: melindaw@cookchildrens.org.