While most pediatric injuries occur outside of school, the school nurse will see and treat a variety of injuries during the school day. The playground, PE class, and athletic events account for the majority of injuries at school. Most of the injuries sustained are accidental and minor, but there are times when the nurse will be called to respond to and assess a student (or staff member) who has sustained a major or traumatic injury. Keeping with the triage pattern of Non-urgent/ Urgent/ Emergent, consider the following points when assessing and intervening for head injury, musculoskeletal injury, and spinal cord injury.
Most head injuries seen in the school clinic are minor. And while assessment, simple interventions, and parent notifications are still necessary, the injury is mostly non-concerning. It’s the more severe head injuries that require keen observation skills, and quick intervention that we must be prepared for.
The school nurse has the knowledge and skills to recognize a suspected concussion injury and assist students during their post-concussion management at school.
A concussion is a mild form of traumatic brain injury that alters how your brain functions and results from blows to the head, falls, crash impact, and injury during a contact sport. Symptoms of a concussion come on rapidly and will resolve spontaneously over a short amount of time. Suspect a concussion when any of the following symptoms are noted:
- Headache after injury
- Confusion, cognitive delay, can’t concentrate
- Blurred or double vision
- Loss of consciousness
- Behavior changes
This student should not go back to class. Call the parent, send home head injury form, and refer for medical care. Call EMS, if necessary.
A student diagnosed with a concussion will likely have activity restrictions upon returning to school. The nurse should be aware of these restrictions and collaborate with school staff to meet the needs of the student.
Traumatic Brain Injury
More severe TBI is when the movement of the brain resulting from impact results in bruising, fractures, and even distortion of the shape of the brain. This is a severe and emergent injury. Assess for the following:
- Mental status, loss of consciousness
- Sensation, ability to move extremities
- Pupil size and reaction
- Bleeding or discharge from ears or nose
- Signs of skull fracture
EMS should be called, and the parent notified. The nurse should remain with the victim to monitor closely and support ABCs. Keep the victim still and calm. You can apply direct pressure to any bleeding head wound, unless there’s a fracture. Quickly assess for any other injuries.
Student’s returning from TBI will likely require more long-term modifications at school. Referral to the 504 committee and a possible IHP would be appropriate.
Musculoskeletal injuries can range from minor strains to major open fractures.
· Non-urgent—strains- mild edema, mild pain, able to bear weight
-Cold pack, elevate, notify parent
· Urgent—sprain, dislocation, closed fracture- moderate deformity, swelling, pain/guarding, cannot bear weight
-Immobilize, cold pack, elevate, assess neurovascular status, call parent- student needs medical attention
· Emergent—open fracture, amputation, joint deviation, suspected femoral fracture
-Call 911, control any bleeding, immobilize, keep victim calm/warm, assess neurovascular status
Immobilizing a fracture/dislocation in upper extremity
- Place arm across chest. Bring bandage over arm and behind neck.
- Adjust length, and tie the ends. The arm should be well supported.
- The knot you tied should lie over the shoulder, not the back of the neck. You may place padding under the knot.
- Secure the sling at the elbow with a safety pin to create a pocket for the elbow to rest. Assess neurovascular status.
Spinal Cord Injury
Spinal cord injuries result most frequently from falls, dives, motor vehicle accidents, and sports activities. The injury can occur along any part of the spine and includes bruising, laceration, transection, or injury to the vessels supplying blood to the spinal cord.
A spinal cord injury should always be suspected in a trauma victim, and EMERGENT interventions are always necessary (911).
Signs and symptoms of a spinal cord injury may include decreased movement or sensation in extremities (upper/lower based on location of injury), parestesia, extreme back, neck, and/or head pain.
The most important thing is that the victim not be moved, unless they are in immediate danger. Maintain spinal stabilization (in the position you found the victim), call 911 and a parent, remain with the student and keep them warm and calm. Ask the student if there is any pain, numbness, or tingling in any extremity. Perform a neuro assessment using the AVPU acronym. If the airway is compromised, avoid using the head tilt-chin lift technique to maintain the airway. Instead, use the jaw thrust method. Assess for any other injury that may need emergent intervention.
A traumatic injury can happen to any part of the body. For this section, we will focus on injuries sustained by severe, blunt force or penetration, fall, or violent mechanism of injury. All of the following traumatic injuries are EMERGENT and require immediate interventions.
- Head Injury- skull fracture, TBI, cerebral contusion, cerebral hemorrhage
- Spinal Cord Injury
- Chest Injury- open chest wound, pneumothorax, hemothorax
- Abdominal Injury- internal bleeding, hollow organ injury (leaking), solid organ injury
- Extremity Injury- fracture, deep wound, amputation
- Skin Injury- deep wound, severe burn
Assessment and interventions need to happen quickly in traumatic situations. Always check and make sure the scene is safe for you to enter. Make sure the victim is not in any danger in their current location.
- Activate EMS immediately
- Assess and support ABCs
- Keep the victim still and maintain spinal stabilization.
- If an object is impaled, keep it in place and stabilize with dressing
- Control any bleeding
- Immobilize suspected fractures
- Provide continuous RN monitoring and frequently assess vital signs and mental status until EMS arrives
- Notify parent
Recovering from a traumatic injury involves more than just physically healing. The victim will need emotional as well as physical support. Long-term accommodations at school may be necessary. Referral to the 504 committee and a possible IHP would be appropriate.
Shock is a life-threatening condition caused by the body not getting enough blood flow. Cells and organs do not get enough oxygen and nutrients and become damaged quickly as shock progresses. This condition is EMERGENT and requires immediate intervention. There are 5 types of shock (anaphylactic will be covered at a future time):
· Hypovolemic- blood loss; significant decrease in total blood volume
· Cardiogenic- heart is damaged, not enough blood being pumped
· Neurogenic- damage to nervous system, no flight/fight response; vessels relax, weakening circulation
· Septic- infection; low blood pressure
Activate EMS and assess victim’s ABCs. Assess mental status, and skin- may be cool/clammy, diaphoretic, pale, or blue; breathing may be shallow, pulse weak and thread, and the victim may or may not be conscious. If you are able, place the victim in the shock position- on their back with legs elevated 12 inches. Do not elevate the head. If you can’t elevate the legs without causing further harm, leave them flat.
1. If bleeding is occurring over a depressed skull injury, you should hold pressure on it?
2. What are some common s/s of head injury?
a. Blurred or double vision
d. Change in LOC
e. All of the above
3. A student has run head first into a pole on the playground. Which one of the following s/s should you be most concerned about?
a. Brief period of confusion immediately after the injury
c. Depressed area on skull at point of impact
d. Pain at area of impact
4. A student fell off the monkey bars on the playground; you are called to the scene. His vital signs are stable, but his leg is visibly deformed with an open wound. Bleeding is controlled. What triage category would you classify this injury?
5. When manually stabilizing the cervical spine, all are correct except:
a. Position the student prone
b. Place both hands along the lateral aspect of the student’s head
c. Position the head so that the neck is in neutral alignment with the spine
d. Continue to support the head to maintain neutral cervical alignment
6. A student fell off of some playground equipment and is now complaining of severe pain in his forearm. What should you do?
a. Move the student away from other children
b. Assess the child and call 911
c. Assess the child and stabilize the arm
d. Apply ice and observe the student
7. Three types of mechanisms of injury are:
a. Direct force
b. Twisting/rotational force
c. Indirect force
d. All of the above
8. You note a Babinski reflex in a victim of suspected head or spinal cord injury. You know that this finding is:
a. An abnormal response
b. A normal response
c. A hyperactive response
d. A diminished response
1. b; 2. e; 3. c; 4. b; 5. a; 6. c; 7. d; 8. a