Special populations, injury that changes the rules

IM injections are painful, absorb unpredictably, and frighten children; the intranasal route avoids a needle.

Intranasal fentanyl (about 1.5–2 mcg/kg via an atomizer) gives fast, effective analgesia for a child with a fracture before IV access, without a needle. Pain is treated early, then reassessed.

Anxiolysis is not analgesia; the fracture pain still needs an opioid, and intranasal fentanyl needs no needle.

Codeine is contraindicated in children under 12 because variable metabolism can cause fatal respiratory depression.

PCC is for an anticoagulated patient with intracranial hemorrhage or other life-threatening bleeding, not a preventive measure after a negative scan.

Vitamin K reverses warfarin for days, leaving a patient with an indication for anticoagulation unprotected, and it is not indicated without bleeding.

With a normal head CT and GCS 15, a therapeutic INR is not reversed routinely; reversing exposes the patient to thrombosis risk for a small chance of delayed bleeding. The patient is observed and given return precautions, with repeat imaging for any change.

Plasma reverses warfarin slowly with a large volume load; it is not indicated without bleeding, and PCC is preferred when reversal is needed.

High-voltage current heats deep tissue, especially muscle near bone, so the skin can look minor while the compartments swell. A tense forearm with pain on passive finger extension is compartment syndrome and needs fasciotomy, often with nerve decompression.

Elevation reduces arterial inflow to a compartment that is already ischemic; the limb is kept at heart level.

Compression adds external pressure to a compartment that is already too tight.

Escharotomy releases a tight circumferential burn eschar; it does not decompress swollen muscle beneath the fascia.

A 6.5-mm tube fits an older child or small adolescent and would injure a 4-year-old's airway.

5.5 mm is larger even than the uncuffed estimate of 5.0 mm ((age ÷ 4) + 4); a cuffed tube this size risks subglottic injury.

For a cuffed tube in a child, the internal diameter is estimated as (age ÷ 4) + 3.5, so a 4-year-old needs 4.5 mm. Tubes a half-size larger and smaller are kept ready.

A 3.5-mm cuffed tube fits an infant; for a 4-year-old it is too small and increases resistance.

A normal fetal baseline is 110–160 beats/min; 175 is tachycardia. After trauma it can signal maternal hypovolemia, hypoxia, or placental abruption before the mother's vital signs change, so continuous monitoring and obstetric evaluation follow.

Bradycardia is a baseline below 110; 175 is the opposite.

The normal range does not extend to 175 at any viable gestational age.

Maternal pain does not explain sustained fetal tachycardia; after a crash, abruption and maternal shock must be ruled out.

Five to fourteen days after an oral commissure burn, the eschar falls off and can expose the labial artery, causing brisk bleeding. Parents are taught to pinch the lip between the fingers and seek care at once.

Ice chips are not the key safety teaching and can be a choking hazard in a toddler; the priority is delayed arterial bleeding.

Removing the eschar can trigger the very bleeding parents should be prepared for; the wound is kept clean but undisturbed.

These burns need surgical or burn follow-up because of the risk of bleeding and scarring that limits mouth opening.

Pain with movement is expected with a hip fracture.

Repeated falls are common in older adults and point to fall risk, not specifically to mistreatment.

An unexplained delay in seeking care for a painful injury such as a hip fracture is a red flag for neglect or abuse. The nurse screens the patient privately and documents the history carefully.

Bruising at the site of a fall injury is expected and consistent with the history.

A forward fall bruises the hands, wrists, knees, and face, not the inner upper arms.

Fragile skin bruises easily, usually on the forearms and backs of hands, not in a symmetric fingertip pattern.

Anticoagulants cause larger, irregular bruises in exposed areas, not patterned bruises matching fingertips.

Oval, fingertip-shaped bruises on both inner upper arms match forceful gripping, a protected area unlikely to be hit in a fall. With a history that does not fit, the nurse reports suspected elder abuse.

Alkali injury is the more progressive type; brief irrigation leaves chemical in the tissue.

Alkalis cause liquefaction necrosis that keeps penetrating tissue, so they need prolonged irrigation, often 30 minutes or more, until the skin pH normalizes. Acids cause coagulation necrosis that limits their own spread.

Withholding water lets the alkali continue to burn; copious irrigation is the first step.

Neutralizing produces heat and delays irrigation; water is the treatment for both acids and alkalis.

Benzoylecgonine, the cocaine metabolite on urine screens, stays positive for about 2–4 days after use, so a positive result does not prove the current agitation is from cocaine. Head injury, hypoxia, and shock must still be excluded.

The screen detects past use; anchoring on it can miss a brain injury or hemorrhage causing the agitation and tachycardia.

A drug screen says nothing about brain injury; intoxication and TBI often coexist.

Cocaine metabolite immunoassays are quite specific; the result is real but its meaning is limited.

A frontal bruise with a normal GCS and behavior is low risk in a school-age child.

A falling GCS and repeated vomiting are high-risk findings for intracranial injury in children, and they call for CT or extended observation. A decline in mental status is never compatible with discharge.

A mild headache that improves is common after minor head injury and fits discharge teaching.

Resolved dizziness with a normal exam fits a concussion managed at home with teaching.

Induction can be used after fetal death in a stable mother, but this mother is in shock with signs of hemorrhage that labor will not stop.

Repeated imaging delays hemorrhage control in a hypotensive patient; the bedside picture already calls for surgery.

Maternal shock with a rigid abdomen after high-energy trauma points to intra-abdominal or uterine hemorrhage, such as uterine rupture or major abruption. With no fetal heart tones, all effort goes to the mother: activate massive transfusion, keep left uterine displacement, and move to the operating room.

Tocolytics treat preterm labor in a stable mother; here there is no fetal heart rate to monitor, and the mother is bleeding.

Adding people does not make a 400-lb lift safe; draw-sheet lifts cause staff injuries and uneven movement.

A standard board still needs a heavy pull that exceeds safe lifting limits for staff and can shift the fractured pelvis.

Self-scooting is unsafe with pelvic fractures and stresses the injured ring.

An air-assisted device floats the patient on a cushion of air, cutting the pulling force several-fold and keeping the pelvis aligned. Bariatric safe-handling guidance favors these devices over manual lifts for patients of this size.

Prophylactic systemic antibiotics are not routine for electrical burns; the priority is trauma evaluation.

A normal ECG can support discharge after a low-voltage injury, but high voltage plus a fall needs admission and evaluation.

Focusing on small entry and exit burns misses blunt injuries from the fall and the deep tissue damage that the skin hides.

High-voltage injury often throws the victim or causes a fall, and violent muscle contraction can fracture bones. A 15-foot fall is a high-risk mechanism, so the patient gets a full primary and secondary survey with spinal precautions, along with ECG monitoring.

Severe localized pain and pigmented urine are not anesthesia effects; dismissing them risks kidney failure and muscle loss.

In patients with severe obesity, hours on the operating table compress the gluteal and lumbar muscles, causing gluteal compartment syndrome and rhabdomyolysis. Severe buttock pain and dark urine call for CK, potassium, and renal function tests, aggressive fluids, and surgical evaluation.

A UTI does not cause severe buttock pain, and dark urine here suggests myoglobin rather than infection.

A skin-only pressure injury does not explain dark urine; the damage is in the muscle beneath.