Clinical Tips

Don't assume silent child is just scared

After a 4-year old girl came to the ED at Cincinnati Children's Hospital Medical Center with an injury from falling off a diving board into a swimming pool, she was in acute respiratory distress, but she had no identified injuries. She had normal vital signs and a Glasgow Coma Score of 15.

During the initial assessment of airway, breathing, circulation, and disability, the physician team leader reported that the patient now had an altered mental status, recalls Gordon Lee Gillespie, RN, one of the ED nurses who cared for the patient.

The team then learned that the girl had hit her head on the diving board before falling into the pool. Since this meant that an acute head injury was now suspected, the team prepared for an elective intubation. "The pre-hospital providers reported that they had assumed she had not been responding to them because she was afraid of strangers," he adds. "This misconception led to a delay in the identification of a possible head injury at the scene."

If the ED had been notified of this, intubation equipment and medications could have been ready upon the patient's arrival.

Although children might in fact be wary of strangers, crying is a more normal response than silence or unresponsiveness, says Gillespie. "To identify if the patient is acting age-appropriately, perform a more detailed neurological assessment and interview the patient's parents."