Kids Do the Darnedest Things: Summertime Injuries and Maladies

Summertime! And the Living Is Risky
Summertime! And outdoor play is at its peak. For the vast majority of kids — appropriately supervised and sun-blocked — that is a net positive, as families head to the beach, campgrounds, and outdoor sporting events. But seasonal injuries and illnesses will affect many, and that will require a visit to the office or emergency department. Medscape presents a quick refresher (complete with links to more in-depth coverage) on summer's associated injuries and risks.

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Submersion Injuries
The most feared of childhood risks in the summer, drowning, is the second leading cause of death for children younger than 5 years.^[1] Residential swimming pools are the most common venue, and a swimming pool is 14 times more likely than a motor vehicle to be involved in the death of a child younger than 5 years. Four times as many children receive emergency department care for nonfatal injuries for every child that dies. Although the immediate effects can obviously be catastrophic, later secondary effects from near-drowning episodes warrant close observation. Aspiration of very small amounts of fluid, a teaspoon or less, can lead to significantly impaired gas exchange. This may be exacerbated if the event occurred in hyperosmolar salt water. Injury to other systems is largely secondary to hypoxia and ischemic acidosis. Chemical pneumonitis is a risk, especially if the submersion occurs in a chlorinated pool. Infection in the sinuses and lungs, as well as other, less common sites, may result from unusual soil and waterborne bacteria, amoebas, and fungi.

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Diving Injuries
The second significant category of water-related injury is those that occur secondary to diving. Cervical spine injuries associated with diving, although rare, often involve the cervical spine and therefore may cause a lifelong severe disability. The incidence of spinal cord injuries following a diving accident has been reported to range from 1%-21%.^[2] These injuries occur predominantly in a young and healthy population that is mostly male. Although diving rules have lowered the probability of injury during supervised athletic events, unsupervised swimming and diving into shallow water present significant risks. Any diving injury must be treated as an emergency, and the cervical spine must always be considered injured until proven otherwise. Immobilization of the neck in a neutral position until a fracture is ruled out is mandatory.

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Heat-Related Illness
Heat illness occurs on a continuum ranging from minor illness, such as heat cramps (typically in the legs) or heat rash, to heat exhaustion, with such symptoms as nausea, vomiting, headache, fatigue, anxiety, and potentially syncope. Heatstroke is the most severe form of the heat-related illnesses and is defined as a body temperature higher than 41.1°C (106°F) associated with neurologic dysfunction. Heatstroke and deaths from excessive heat exposure are more common during summers with prolonged heat waves. Infants and children are at particular risk owing to inefficient sweating, a higher metabolic rate, and their inability to care for themselves and control their environment. Risk factors include a preceding viral infection, dehydration, fatigue, obesity, lack of sleep, poor physical fitness, and lack of acclimatization. Cooling and rehydration are critical.

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Concussion
The past few years have brought increasing awareness of the critical importance of early recognition and appropriate management of concussion. Summer activities carry their share of risk for concussion owing to any number of potential events, such as a fall from a bike, a hit with a baseball, a collision during a soccer game, or a motor vehicle accident. The diagnosis is clinical, based on a thorough systematic evaluation of the injury and its manifestations; routine imaging studies of the brain are typically normal. Children are at particular risk for prolonged symptoms of headache, dizziness, fatigue, and emotional lability.

And kids with a history of concussion are at an increased risk of sustaining a subsequent concussion.^[3] Neuropsychological testing should be strongly considered for children whose symptoms persist beyond 1 week. Physical and, even more important, cognitive rest are the mainstay of management.^[4] And perhaps somewhat easier to accomplish in the summer!

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Acute Otitis Externa
Acute otitis externa (AOE) presents primarily during the summer months, as heat and moisture aid in the invasion of bacteria into tissue of the external auditory canal. Although AOE is common in all age groups, peak incidence occurs in 7- to 12-year-old children. Most cases are caused by a bacterial pathogen; the most common bugs are Pseudomonas species, Staphylococcus species, and gram-negative organisms. The condition presents as pain and sometimes pruritus along the auricle and external auditory canal, without mastoid tenderness. Although the pinna generally appears normal without protrusion, edema, erythema, or warmth, tenderness on manipulation of the tragus or pinna is almost diagnostic. Erythema, edema, and exudates may be seen in the external auditory canal, with edema sometimes so significant that the tympanic membrane cannot be visualized. AOE is treated with any number of topical regimens, including acetic acid, quinolones, or polymyxin/neomycin. Topical steroids have been shown to be beneficial. In rare instances, cellulitis affects the localized bone, leading to osteomyelitis requiring intravenous antibiotics.

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Rhus dermatitis
It wouldn't be summer without rhus dermatitis, an allergic contact dermatitis to members of the plant genus Toxicodendron, which includes poison ivy; poison oak; and, less frequently, poison sumac. Approximately 50%-70% of the US population is susceptible if exposed casually, a number that rises with sustained exposure. Extreme sensitivity occurs in 10%-15% of people. Whereas some children will report known exposure, many are exposed unknowingly, either through play or pets that come in contact with the plant. Washing exposed areas with copious amounts of water within 20 minutes of exposure has been shown to reduce reactivity. The hallmark lesion is linear, erythematous, possibly edematous, and pruritic and may vesiculate. Topical preparations, such as Domeboro®, calamine, oatmeal baths, and Burow solution are the standard of care. Oral antihistamines may relieve pruritus, especially in severe cases where urticarial lesions and bullae occur. Low-dose steroids and topical antihistamines have not been shown to be beneficial, although systemic steroids are indicated in severe cases. Oral analgesics occasionally are required for very severe cases.

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Sunburn
Sunburn, typically a superficial first degree burn due to excessive exposure of the skin to ultraviolet radiation, can come from a variety of sources, including tanning beds and phototherapy lamps, but summertime sun is far and away the main culprit. Despite years of sunscreen warnings, over one half of all US children experience a sunburn during the course of a year.^[5] Although the majority of these children will never present to a healthcare provider, many (notably children who are fair-skinned, blue-eyed, and blond or red-headed) may well sustain an inflammatory response, peaking 12-24 hours after exposure, that can result in edema and blistering. Symptomatic therapies, such as cool compresses and emollients, are the mainstay of treatment. Topical steroids, although often used, are only minimally effective.^[6] Over-the-counter analgesics may be used, even though evidence for these agents is also limited.^[7] Children with more significant second-degree burns may require more aggressive therapy, including fluid resuscitation.

Insect Bites and Stings
Although the terms "bite" and "sting" are often used interchangeably, bites are the result of feeding by an insect (typically mosquitoes, fleas, mites, and bedbugs) and cause itching. Stings occur from contact with a stinging apparatus that pierces the skin and releases venom (typically from bees, hornets, wasps, and scorpions). These hurt! Insect bites and stings peak in the summer. Wheals and urticaria generally appear within minutes, causing itching, moderate pain, erythema, tenderness, warmth, edema, and an absence of systemic symptoms. A severe local reaction with generalized erythema, urticaria, and edema increases the likelihood of systemic reactions, ranging from mild to fatal, with subsequent exposure. Anaphylaxis can begin with local symptoms and rash and urticaria in areas not contiguous to the bite. It quickly progresses to anxiety, disorientation, syncope, hypotension, and cardiovascular collapse. Systemic reactions can be delayed as long as 10-14 days and can resemble serum sickness. Routine wound cleaning followed by ice is often all that is needed. Epinephrine is the mainstay of prehospital treatment of a systemic reaction.

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Wounds
Summertime, with its myriads bangs, bruises, lacerations, and abrasions, is a time of increased risk for secondary infections with increasingly common resistant organisms. The increase in wound infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) prompted the recent release of updated clinical guidelines for management from the Infectious Diseases Society of America.^[8] A new algorithm addresses purulent vs nonpurulent staphylococcal infections (abscesses, furuncles, and carbuncles) and allows for classification as mild, moderate, or severe. Purulent cases should be treated with incision and drainage; antibiotics should usually be avoided except in cases associated with systemic symptoms, such as fever. Topical products may be used in mild cases, though resistance to these agents is increasing. In contrast, even mild or moderate nonpurulent cases typically require antibiotics; severe nonpurulent infections should be surgically debrided. Individualized therapy is paramount and should be directed by clinical symptoms and local antibiograms.

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Food-borne Illness
Summer would not be complete without a picnic or two. The most recent data from the Centers for Disease Control and Prevention underscore the continuing high incidence of food-borne diseases (FBDs), well above national Healthy People 2020 targets and highest among children younger than 5 years.^[9] Typically, FBDs present with severe vomiting (eg, staphylococcal-toxin gastroenteritis) and small-bowel diarrhea (eg. Vibrio cholerae infection). Salmonella infections are among the most common and account for the largest number of hospitalizations and death. Enterohemorrhagic Escherichia coli-induced diarrhea, which may lead to hemolytic-uremic syndrome, is a particular concern in the youngest children. Determining the period between ingestion of the suspected food and the onset of symptoms can go a long way toward identifying the etiology. Beware of the group picnic leading to illness in an entire family! Stool culture is an expensive and often low-yield test. Treatment is supportive, with fluid and electrolyte replenishment, and antibiotics are usually not warranted.^[10]

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