2018 UF ED/Trauma Symposium

1. Pediatric Injury Prevention
Marie Crandall, MD, MPH, FACS
Professor of Surgery
Associate Chair for Research

2. 2
Overview of Injuries in Childhood
• Unintentional injuries are the leading cause of death in children from
1 - 21 years of age in the U.S.
• Each year, 20-25% of children sustain an injury requiring medical
attention, missed school, and/or bedrest
• Leading cause of childhood medical spending in U.S.

3. Average Day in U.S.
• > 80,000 injuries resulting
in hospitalizations and ED
visits; >28,000 in kids 0-19
y.o.
• > 400 deaths due to
injuries; > 50 in kids 0-19
y.o.
Source: National Center for Injury Prevention and control, 2008

4. Childhood Injuries - Deaths
0
10
20
30
40
50
60
70
80
90
1-4 yr 5-9 yr 10-14 yr 15-19 yr
1955
1967
1988
1998
2001
2006
% total mortality
Source: National Center for Injury Prevention and Control, 2008

5. Mortality after Pediatric Trauma Admissions
0
0.5
1
1.5
2
2.5
3
3.5
4
<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age
%
NTDB Pediatric Annual Report, 2009

6. Functional Outcomes after Trauma
Children
• 10-25% with severe injuries have
functional limitations
• 30% of LE fracture and 15% of UE
fracture have physical limitations at
12 mos.
• 2% of mild TBI, 50% of moderate TBI
and >90% of severe TBI have
disability
• 20% of children and 40% of
adolescents have signs of PTSD
Adults
• 50% are not back to work at 1
year
• 35% report health as fair-poor at
1 year
• 40% of elderly have difficulty
walking
• No effect of TC care on functional
outcomes in TBI or elderly
• 40% of adults have PTSD sxs at
one year

7. Injury Pyramid
Deaths
147,891
______________
Hospital discharges
2,591,000
____________________________
Emergency department visits
36,961,000
________________________________________
Episodes of injuries reported
59,127,000
1/18
1/14
2/3
|-------------------------------
|
|
|
1/400
|
|
|
|
|
|-------

8. U.S. Death Rates for Infections and Injuries, Ages 1-19
Injuries

9. Why has there been success in other areas of child
health versus injuries?
• Increase in new knowledge and development of new technologies has
been responsible for most of the advances and gains in life
expectancies.
• Efforts to improve health systems and policies have been central to
success in these other diseases
• Increases in life expectancies  increased incomes and GDP

10. Resources for injury control
YLL DALYs WHO
reg. $
WHO
extra $
Communicable disease & maternal,
perinatal and nutritional conditions
54% 41% 68% 91%
Non-communicable dis. 33% 47% 31% 8%
Injuries 13% 12% <1% <1%
Lopez, The Lancet Nov 2008

11. 11
Basics of Injury Prevention
• INJURIES ARE NOT ACCIDENTS
• Injuries are often understandable, predictable, and preventable
• Specific injuries share similar characteristics of person, place , and
time
• By understanding injuries, interventions can be developed and
implemented to prevent or limit the extent of a given injury

12. 12
Strategies for Prevention
Intervention or countermeasures are classified based on requirements
for behavior change
• Active - rely on actions taken by an individual (e.g. keeping firearms in
locked cabinets)
• Passive - do not rely on the efforts of an individual to be successful
(restricting access to firearms)

13. 13
Methods of prevention: “The Three Es”
• Engineering
• Environmental change
• Education

14. Bicycles
• 700-900 people die in bicycle-related
injuries each year in the United States
• The majority of bicycle injuries occur in
children less than 15 years old
• 90% of patients killed in bicycle crashes
were not wearing helmets

15. Why Wear a Helmet?
• The skull is less than a ¼ inch thick.
• You do not need to be going fast or fall far to
injure the brain.
• Children riding a tricycle should wear a helmet.
• Bicycles are not toys, and should be considered a child’s first vehicle.

16. Bicycle Injury Prevention Research
Helmets provide a 63% to 88%
reduction in the risk of head, brain
and severe brain injury for all ages
of bicyclists.

17. Bicycle Injury Prevention Research
18% reduction in head
injury crashes among
children versus adults
who were not subject to
the law.

18. Bicycle Injury Prevention Research
Racial disparities in helmet use; little effect if no primary
enforcement.

19. Pediatric Firearm Injury Statistics
• 30,000+ firearm-related
deaths/year in the United States
• 12,000 homicides, 20,000
suicides
• 110,000 firearm injuries that are
brought to medical or legal
attention

20. Pediatric Firearm Injury Statistics
• 4 children killed daily by guns
• 50 injured seriously
• 40% American households have
guns
• 1.7 million children live with
unlocked/loaded guns in the home
(that’s 40% of the 40%)
• 75% of kids know where “hidden”
guns are in the home

21. Firearm Injury Prevention Research
7-40% reduction in
firearm related injuries in
states with stricter
licensing. No effect with
concealed carry laws.

22. Firearm Injury Prevention Research
13% reduction in firearm suicides.

23. Firearm Injury Prevention Research
Unlocked, loaded weapons
much more likely to be
associated with youth firearm
injuries and suicides.

24. Firearm Injury Prevention Research
Firearm injury admissions
much more common in
states with lenient gun
laws.

25. Firearm Injury Prevention Research
Guns 2x as likely in the
homes of suicide victims
as in homes of suicide
attempters.

26. Restraints

27. 10 year old Male
• Back seat passenger
• Wearing lap belt ONLY
• MVC going 40 mph
• No LOC, no vomiting
• ABCs intact
• GCS 15
• + Seatbelt Sign
• Right hip TTP

29. 3 year old Female
• Sitting in aunt’s lap in backseat
• MVC at 40 mph
• + LOC
• GCS 9 at scene
• In trauma center:
• Intubated
• Bradycardic
• Hypertensive

31. Motor
Vehicle
Crashes
• LEADING CAUSE OF CHILD DEATH
• Car seats reduce risk of injury and fatality
• Especially in infants & toddlers
• Up to 7 out of every 10 children are improperly
restrained

32. AAP 2011 Recommendations
Age Restraint
Up to 2 years Rear-facing car seat
Up to 4 years Forward-facing car seat
Up to 8 years Belt-positioning booster seat
Outgrown Booster Seat Lap-and-shoulder seat belts
Up to 13 years Ride in the back seat

34. Clear as Crystal?
Clear as Mud?
• www.healthychildren.org
• www.nhtsa.org
• www.safekids.org

35. Car Seat
Programs
• Car Seat Screening
Programs
• ED/Trauma
• Primary Care
• Child Passenger Safety
(CPS) Certification
• Community

36. Falls

37. 7 year old Female
• Playing at park after school
• On the monkey bars
• Fell on outstretched arm

39. Fall out of two story
window
• 5 year old boy
• History ADHD
• Beautiful 70 degree sunny day

41. Falls
Leading cause of non fatal injury
for children 0-19 years (CDC)
8,000 ED visits every day
Leading cause of hospitalization
for ages < 14 years

42. While Playing
• Playground Deisgn - woodchips
or sand (no dirt, concrete, grass)
• Helmets – inline skating,
skateboarding, bicycle, ATV, dirt
bike
• Supervision

43. Home
• Window guards and/or stops (screens keep
bugs out)
• Move furniture away from windows (kids climb
up)
• Stair gates
• Secure young children when seated
• Never leave children alone in shopping carts

44. Burns

45. 3 year old
female

47. Scald Burns
• Younger children
• Traditional Counseling: Set hot water
temperature at 120 degrees F
• Closer monitoring in high risk areas
(kitchen, bath)
• Safety gates around fireplaces, ovens,
furnaces
• Cooking safety
• Deep child safe distance away
• Avoid carrying /holding child
while cooking
• Turn pot handles away from the
edge
• Close, snug-fitting clothes

48. Teenage
boys
“hanging
out”

49. Flame burns
• Older Children
• Fire extinguishers on every level
• Every room with potential for open flame
• Space heaters, kerosene heaters
• Stop, drop, roll

50. 2/3 of household fire
deaths in homes without
smoke detectors or
without working smoke
detectors
Dual smoke
detector/carbon
monoxide alarms
preferred

51. Smoke Detectors
Test Once a MonthTest
Replace Battery Once a YearReplace
Replace Detector Every 10 years (or per manufacturer)Replace
Place on every floor, outside each sleeping area and inside each bedroomPlace on

52. Are injury prevention programs effective?
• Cochrane Reviews
• School-based
programs
• Parenting
Interventions
• Bicycle safety programs

53. The
Future of
Injury
Prevention

54. Resources
• www.injuryfree.org
• www.healthychildren.org
• www.nhtsa.org
• www.safekids.org