How Should I Counsel about Injury Prevention?

Patient Presentation
An 18-month-old female returns to clinic to recheck the second degree burn she received on her arm yesterday.
Her mother was using a curling iron in the bathroom and the child pulled the dangling cord and the hot iron fell on the dorsal aspect of her left arm.
The mother immediately cooled the area with cold water and both parents took her to the emergency room, where the 2×1 cm blister with surrounding erythema was kept intact.
Silvadene ointment was carefully placed on top of the blister and covered with a gauze dressing. The mother was told to give Tylenol for pain and to go to see her local physician after 24 hours.
The mother was also given general wound and fever instructions. The family was also questioned concerning potential non-accidental trauma and family violence and the healthcare provider felt that there were no concerns about these issues currently.
The pertinent physical exam showed a healthy female with a broken blistered area of approximately 2×1 cm with an additional 4-8 mm of surrounding erythema noted.
Toward the distal end of the blistered area appeared one 3-5 mm circular area which was greyish in color.
A complete physical examination found only a few small bruises of different colors on the child’s shins.
The diagnosis of second degree burn with possible small area of 3rd degree burn was made. The wound was again cleaned and covered with Silvadene and a gauze dressing.
Wound instructions and the importance of checking the wound for spreading erythema later in the day was emphasized. The mother was also told to call immediately if the child had a fever and was to follow-up the next day.
The patient’s clinical course consisted of 2 more daily wound checks. She did not develop any complications, but had a 1.5 cm pinkish scar that continued to remodel at her 3rd year well child examination.

Discussion
Burns are common problems, especially minor burns.
The depth of the burn is defined as:

  • First degree – erythema of the skin, e.g. sunburn
  • Second degree (partial thickness of skin) – blistering, swelling, and moist surface appearance
  • Third degree (full-thickness of skin) – charred, waxy appearance, white/grey in color and may be dry
  • Fourth degree (devastating full thickness) – burn goes into muscle and/or bone

The “rule of 9s” is used to estimate the amount of body surface area (BSA) involved. For children the head contributes more and the upper legs less. In general, an area the size of the palm of the hand is 1% BSA.
For older children and adults BSA can be estimated as:

  • Head/neck – 9%
  • Each arm – 9%
  • Anterior thorax – 18%
  • Posterior thorax – 18%
  • Each leg – 18%
  • Perineum – 1%

Learning Point
Injuries are the leading cause of death and life-years lost for people under 44 years of age in the U.S.
Data regarding the most common injuries by age group is provided by the Centers for Disease Control at: http://www.cdc.gov/nchs/data/dvs/lcwk1_2003.pdf

To understand what leads up to an injury, in 1980, Haddon defined 3 phases; pre-event, event and post-event. The contributing factors are cross-tabulated with the categories: host (victim), agent (vector or vehicle), and environment (both physical injury scene and the sociocultural/socioeconomic).
A Haddon matrix for the burning above could look like this:


Category	Pre-event  		Event 			Post-event
Host		Lack of knowledge 	Inability to move  	Burn on arm
(child)		- "Don't touch"		out of way

Agent		Hot iron on counter  	Dangling cord verus 	Result of curling iron
(curling iron)	cordless model					injury including burn
								to otherpart of body
								or mother

Environmental  	Bathroom door open	Curling iron on vanity, Immediate burn treatment
(injury scene)	Mother distracted	cord easily seen and 	at home, Emergency room
					grabbed, Hot iron	treatment
					present

Environmental  	Burn education, 	Psychological stress  	Emergency room and
(socioeconomic	purchase cordless  	on patient and mother	primary care physicians
/cultural)	model, Economic losses				office care, potential burn
		of family					unit and rehabilitation care

Injury prevention is organized into 4 E’s:

  • Engineering to eliminate or decrease injuries by modifying the agent or product, e.g. decreasing the amount of acid in the bottle of false-nail etcher to decrease burns, alerting sounds on trucks that are backing-up to prevent driving over a pedestrian.

    This is theoretically one of the easier strategies to implement because once implemented they often do not require a person to do anything else, i.e. they are passive strategies. Many of these are also relatively low-cost. For example, replacing strings on the hooded children’s clothing with elastic to prevent strangling injuries

  • Enforcement to have laws or regulations that modify individual behavior, e.g. mandatory child restraint use in cars, mandatory bike or motorcycle helmet laws.

    Laws and regulations can make strategies easier to implement because of the social and economic pressures for individual behavior conformity or because they are passive strategies. For example, graduated driver’s licenses decrease motor vehicle accidents and flame-retardant placed on children’s clothing during manufacturing decreases burn injuries.
  • Education to inform and persuade individuals to adopt or change their individual behavior, e.g. using cord hooks on window blinds to prevent strangling injuries, using trigger locks on all guns, learning to swim.
    This should be advocated, however it requires active action to consistently implement and therefore can be difficult to do. However it can be effective for persons ready to learn and motivated to change their behavior.

  • Economics to create financial incentives to implement injury prevention strategies, i.e. car insurance discounts for families whose teenagers complete safer driving programs, government funding to build or modify separate bicycle trails or skateboarding parks from traffic areas.

    Economics can be a problem for many families. For example, the cost of placing window guards in a high rise building could be prohibitive for the individual family and/or the building owner.

Injury prevention screening and education of the patient and family at all visits including health maintenance visits is important. The American Academy of Pediatrics uses TiPP sheets based on child age to assist healthcare providers and families with this education.
As all possible injuries cannot be assessed and discussed at every visit, guidance must be individualized based upon several factors including:

  • Age – e.g. falls and choking hazards for infants, driving and suicide risks for teenagers

  • Developmental skills – e.g. able to climb on furniture or playground equipment and trees
  • Time of year – e.g. heat and cold injuries in summer and winter, fire and carbon monoxide in fall and winter
  • Geographical – e.g. proximity to bodies of water such as lakes, streams, pools, traffic
  • Family livelihoods and recreation – e.g. farm injuries, firearm injuries, lawnmowers, swimming, skiing
  • Resources to mitigate risks – e.g. purchase cabinet locks and gates, paint over peeling leaded paint

Questions for Further Discussion
1. What are some of the most common injuries in your local area and why?
2. What are some of the methods that could be employed to decrease a common local injury?
3. What are some of the government agencies who are responsible for decreasing injuries?
4. When should screening for child abuse and family violence occur? How can a healthcare provider do this screening?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Burns and Injuries
and at Pediatric Common Questions, Quick Answers for these topics: Burns and Child Safety

To view current news articles on this topic check Google News.

Haddon W. Options for the prevention of motor vehicle crash injury. Isr J Med. 1980;16;45-68.

Mace SE, Gerardi MJ, Dietrich AM, et.al. Injury Prevention and Control in Children. Ann Emer Med. 2001:38(4);405-413.

Centers for Disease Control National Vital Statistics System. Deaths, Percent of Total deaths, and death rates for the 15 leading causes of death in 5-year age groups, by race and
sex: United States, 2003. Available from the Internet at http://www.cdc.gov/nchs/data/dvs/lcwk1_2003.pdf (rev. 2003, cited 12/13/2006).

Degutis LC, Greve M. Injury Prevention. Emerg Med Clin N Am. 2006:24;871-888.

Shudy M. Lihinie de Almeida M, Ly S, et.al. Impact of Pediatric Critical Illness and Injury on Families: A Systematic Literature Review. Pediatrics. 2006;118(Supp 3)S203-218.

Oliver RI, Spain D. Burns, Resuscitation and Early Management. eMedicine.
Available from the Internet at http://www.emedicine.com/plastic/topic159.htm (rev. 11/17/2006, cited 12/12/2006).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    January 16, 2007