08 Dec The Basics: From Bumps To Bites

Dr Sam Tormey explains the first-aid skills needed to treat common injuries in children. Just in time for the summer holidays!

Contrary to popular belief, things that go bump in the night are not usually monsters, burglars or ghosts. They are usually toddlers jumping off the back of the sofa and trying their best to put a dent in the edge of the coffee table. There’s a typical sequence here that parents all over the world are painfully familiar with: it starts with a strange and suspicious silence from the next room where the kids are playing, followed by a thump, another brief silence, and then a full-throated scream. The kitchen, the playroom, the backyard – all can be trauma central once you have kids that can walk, run and climb.

We’ve all got war stories from the battlefield of early childhood, usually proudly recounted while pointing out the scar, the lump or the wonky nose. Like the prized catch of fishing stories, wounds that only needed three stitches at the time tend to get longer with each passing year. So ubiquitous is our experience of minor trauma in childhood that we tend to think of kids as indestructible, and many of us view our broken bones, burns and cuts almost as rites of passage into adulthood. Children are resilient but certainly not indestructible, and common household trauma is a leading cause of disability and death.

So how can you tell which bump on the head is benign and which one needs a trip to the doctor? What should you do when your child appears in the kitchen with blood spurting from their finger?

The following is a rough guide to help you through those first panicky seconds when your child goes white and looks at you with big, frightened eyes that are pleading, ‘Mum, Dad, help me!’

• Head injuries are one of the most frequent reasons for a visit to the emergency department and are the leading cause of trauma deaths in children. Babies and children have larger and heavier heads relative to body size than adults do. This anatomical difference, combined with relative deficiencies in neck strength, spatial awareness and motor coordination, makes toddlers and infants more prone to head injury than older children and adults.

Contrary to popular belief, babies and children are more vulnerable to head trauma than the rest of us. Think of it this way: we are used to the idea that little kids bonk their heads all the time and nearly always bounce back with little apparent damage, which leads to a mistaken concept of greater resilience. These injuries, however, are generally low-velocity falls from modest heights, and a child is actually more likely to sustain a serious head injury than an adult who falls from the same height. Having a softer, more flexible skull can allow a more severe injury to the brain than the hard, inflexible adult skull. As well as this, growing brains have different wiring (there is less protein ‘myelination’ around the nerves), which means that children can sustain more internal bruising than adult brains given the same degree of trauma.

So which head injuries need kissing better and a rest on the couch, and which need a trip to the hospital?

Your child’s behaviour gives important clues about the severity of the injury. Children who cry immediately after the dreadful thump and who are easy to console (stop crying in less than 10 minutes) are unlikely to be seriously injured and can usually be safely observed at home. Any period of unconsciousness after a head injury, no matter how brief it was and how normal your child seems subsequently, requires a doctor’s opinion. Bruises and ‘eggs’ on the scalp are also associated with higher rates of internal damage and require closer observation. Bruising or bleeding around the brain – the worst-case scenario – causes a progressive headache, vomiting, unsteadiness on the feet and drowsiness or unusual behaviour. These complications are most likely to occur within the first four hours after the injury (often the period of observation if you do go to the hospital), but may be delayed in some cases by up to 24 hours.

Any child who develops a bad headache or who vomits more than once after a head injury should be seen by a doctor, who will consider performing a CT scan of the brain. Children often want to sleep after a head injury, but ideally, they should be kept awake for the first four hours to watch for concerning symptoms. If the four-hour period is uneventful, the child can be allowed to sleep, although I generally advise parents to wake their child once or twice overnight to check that they wake up normally.

Remember that any head injury can also injure the bones in the neck, so a child who is complaining of neck pain or is unwilling to move his or her neck after a head injury should lie down with their head kept still until an ambulance can safely transport the patient with a neck brace fitted. In general terms, the combination of the child’s behaviour after the injury along with the way in which the injury occurred (higher, faster falls onto hard surfaces like concrete are more likely to cause damage) should guide you towards the hospital if necessary.

• Unlike head injuries, cuts and scrapes are generally less severe in children than they are in adults, but the sight of blood often causes greater distress. For deep cuts with arterial injury (obvious spurting), wrap the wound firmly with a bandage or any clean material that comes to hand (but never attempt to tourniquet the limb – when the limb is wrapped so tightly as to cut off the blood supply) before seeking a doctor’s help.

For most wounds, ignore the bleeding initially and wash the wound in fast-flowing tap water. Firm pressure with a gauze pad or a bandage will stop most bleeding, but taking the pad off every three minutes for a look usually means that you are back to square one, so continue with constant pressure over the wound for 15 minutes if possible. Note: Disinfecting wounds with iodine, mercurochrome, and the like has been proven to delay wound healing, as these substances are quite toxic to healing tissue.

It is more important to get gravel, dirt, glass or fragments of shell out of wounds than it is to stitch them up, as any retained object greatly increases the chance of infection. We see lots of clean cuts in the emergency department that don’t need stitching, and we see lots of infected ‘gravel rash’ that needed a good clean on the day of the injury. A local anaesthetic may need to be injected through the wound to allow washing and scrubbing to remove gravel and other debris, and many parents are surprised that some quite large wounds are not then stitched closed afterwards. Dog or human bites, cuts from coral or oysters, and cuts that are contaminated with lots of dirt or mud are actually best left open for two or three days after cleaning to ensure that an infection does not develop. If the wound looks clean on the return visit to the hospital, it can then be safely closed with sutures.

• Burns are another injury where good first aid is available from the kitchen sink or the shower. Large burns or burns around the face (especially the mouth, eyes or nose) should be treated urgently in the hospital, but for most burns, at least 20 or 30 minutes under cool running water at home will minimise the damage, and this is the best thing to do first. Take any clothing covering the burn off as soon as possible, and never use an icepack on a burn. Burns are much more painful than cuts and scrapes, and painkillers should be used early and regularly. After cooling the area with running water, cover the burn with something clean and cool, such as a clean tea towel or bandage soaked in water. Clingfilm makes a great emergency burn dressing, but avoid ointments, lotions or sticky dressings until you have shown the wound to a doctor.
• Like head injuries, choking episodes are an almost universal feature of a normal childhood. While they are usually brief and uncomplicated, like food going ‘down the wrong way’, choking episodes at home do result in deaths each year, usually in the under-three age group. While soft food is the most common cause of these episodes, small solid items such as nuts and toys are more dangerous. Any toy that can fit inside a plastic film canister without poking out is considered to be small enough to be a choking hazard. Beware also of deflated balloons, which have caused several choking deaths in infants.

If a child is choking, let them sit upright and leave them alone. Do not crowd them or fuss over them, and do not offer water. If the child remains conscious and has an effective cough, reassure them and encourage them to continue coughing. Should the cough is getting weaker, and the child is obviously having difficulty breathing, you must intervene. If the object is visible in the mouth and can be easily grasped without the danger of pushing it down further, remove it. This will not be possible in most severe choking episodes, as the object will generally be small and beyond easy reach. The next move is to apply pressure to the chest to simulate a cough and hopefully expel the object.

Babies should be laid belly downwards along your arm or thigh, with their heads angled down towards the floor. While one hand grasps the lower jaw to keep the mouth open, the other hand is used to deliver a series of five firm blows with the heel of the palm to the back of the chest, between the shoulder blades. The same technique can be used for small children, but if this fails, and the obstruction does not clear, and the child becomes increasingly distressed or can no longer cough effectively, proceed to deliver 5 back slaps and chest thrusts.

If a child becomes unconscious at any stage during a choking episode, standard CPR should be commenced immediately – both chest compressions and breaths. It seems wrong to blow air down an obstructed airway, but this is the only way of getting oxygen into the child’s lungs, even if the object is further displaced.

Call the Emergency number  (Triple Zero —OOO).

• Bites and stings are part of any adventurous Australian childhood, and we have some of the nastiest biters and stingers in the world. Common marine stings from creatures such as jellyfish, bluebottles and stingrays are generally more painful than dangerous. Cold water or ice packs can help the pain of blue bottle stings, while warm running water can relieve pain from stingray wounds. Stingrays can leave barbs behind in the flesh, and these wounds have high infection rates, so show the wound to a doctor after the warm-water first aid. If you see a barb in the wound, leave it there and let the doctor take it out with the help of some local anaesthetic.
• Jellyfish stings from tropical waters, where box and Irukandji species may be present, should be doused in vinegar initially. Get help urgently if a stung child has severe pain, vomiting, diarrhoea or headache.
• Unless a true allergy exists, insect stings are not generally dangerous; ice packs and antihistamines are useful if local swelling is painful and annoying.
• Spiders: We have two nasty types of spiders in Australia: small red-backs and large funnel webs. Funnel-web spiders are the more dangerous of the two, and any bite from a big, black spider should be treated as a funnel-web bite. The first aid is the same as for a snake bite: lie the child down and keep them still, then bandage the entire affected limb with firm (but not tight) pressure from a crepe bandage and get help to the patient – in this order rather than the other way around.

Talking of snakes, we Aussies love to think that we can identify them. It is a matter of national pride to say, in an offhand kind of way, that we just ran over a king brown on the way to the footy. In reality, even our snake experts struggle to correctly identify our common snakes without counting scales and inspecting other features. Treat any snakebite as a dangerous one, and treat any unseen bite sustained in the long grass as a potential snakebite. Always have three large crepe bandages on hand if you have a backyard or are out bushwalking or camping – they are genuine lifesavers. The biggest risk factor for snake-bite death is attempting to catch or kill a snake, so teach kids that our native creatures are much more likely to leave us alone if we leave them alone.

Whew! Hopefully, none of these things will ever happen to your child.

To be of most help to an injured child, consider the following simple measures. Firstly, when an accident happens, try your hardest to remain outwardly calm, no matter how you feel on the inside. Injured children need reassurance and comfort – if there is panic happening around them, they will panic too. Remember that an ambulance (Triple Zero phone OOO). will make it to your place faster and more safely than you will make it to a hospital.

It is a good idea to keep a simple first-aid kit with clean gauze, several bandages and a good eyewash solution on hand. (Eyewash in a squeeze bottle is the best way to wash chemicals or objects from the eye – lie the child down and squeeze the solution into the eye while holding both eyelids open with the other hand.)

But by far, the most useful thing that you can do is to acquire basic first-aid skills – these can literally be lifesavers.

Sam Tormey is a doctor who writes on medical issues. His practice is in emergency medicine.

Illustrations by Gregory Baldwin

Australian Emergency phone number is Triple Zero —OOO.

St John Ambulance is a charity that runs first-aid courses across the country. It also sells an excellent range of products all families should have on hand.

Call 1300 360 455 or go to www.stjohn.org.au for further courses or other details.

Note: This article provides general health information and in no way constitutes medical advice. Ideas and information expressed may not be suitable for everyone. Readers wishing to obtain medical advice should contact their own doctor.