Generally, good recovery from road traffic injuries depends on the availability, accessibility and the quality of our accident and emergency units particularly the trauma care services. In many LMIC such services are either not available or limited in scope and quality with Surveys conducted in the Asian countries concluding that most children with injuries do not receive medical care.1
Most of the initiatives in reducing road traffic injuries aim at preventing collisions and on restricting or reducing complications via functional emergency medical services including good pre-hospital care, hospital or emergency care and rehabilitation.
Pre-hospital care:
Many lives can be saved if right from the scenes of road traffic collision the care is prompt, efficient and effective. In places with good emergency medical care such as ambulances equipped with supplies and devices that cover both adult and children, trained staff and functional equipments the prognosis is always good.1
lxviii
Staffs need to be trained and able to differentiate between adult and childhood emergences as what is normal in an adult may be abnormal in a child. Where there is no functional pre-hospital trauma care system, volunteers could be trained on basic techniques of first aid.118Also the volunteers need to identify emergencies and call for help while waiting for trained health care personnel.
In places with no formal emergency services, it is important that structures are raised, equipped and staffed particularly along our busy roads despite the cost of erecting such building as it is an issue of priority.118The growth rate of any nation is assessed by its health care system and indices with good transportation network.
Emergency care:
The second stage of care is when the child enters the hospital which determines the child’s survival.119Improving our health care system is an affordable and sustainable way of reducing morbidity and mortality or outcome of care when we have trained, skilled and equipped hospitals especially in developing countries like Nigeria where our health morbidity and mortality indices are high, Good theaters, functional ambulances for emergencies, stable light to mention a few.1
The challenges confronting the LMIC include the following:26
The long delay between the time of road traffic collision and reaching health care facility.
The lack of trained personnel and availability of first aid services.
Poor and unsafe transport network or services.
Inappropriate and poor referral system.
Also the absence of a good triage system.
lxix Rehabilitations services:
Proper recovery of children following road traffic injury is also dependent on the availability ofgoodrehabilitation services. Such services may be limited in some countries due to lack of rehabilitation personnel, necessary infrastructure for physiotherapy and the availability ofguidelines and protocols for rehabilitation which limits disability particularly among young people either within the health care system or community based thereby improving their quality of life.1
2.4.2 Management of burns:
In-order to reduce morbidity and mortality from burns, the following steps need to be taken into consideration:
Accessibility to treatment and rehabilitation centers:
In many places especially the developing countries the road are in bad conditions if available or there are no access roads to health facilities around particular in the rural settings.1
If the health facilities are available the cost of care is high considering the economic state, literacy and poverty level of our people as only those with means can take their children to hospital resulting in delayed healing, contractures and superimposed infections.138,143
Some families because of difficulty in accessing health care or rehabilitation centers, they first resort to using traditional methods before consulting the health care provider with complications.24,59
First aid care in burns:
The management of burns starts from the location of injury before transporting to hospital.
This usually starts with the family members, by-standers or first responders and should be done after considering the rescuer’s safety. The overall aim is to cool the burn, prevent ongoing burning and prevent contamination of the wound.1,24,59
lxx
A report in India where only 22.8% received appropriate first aid care and the remainder did not or resort to the use of raw eggs, toothpaste, mashed potato or oil rubbed to site of injury while studies from Viet Nam reported that those who had proper first aid care needed 32%
less subsequent grafting.1,51 Acute management:
Once a child with burns has been transported to the health care facility, assessment and stabilization initially focus on a survey of air way, breathing and the circulation. There is need to also do a careful general examination of the child from head to toe for other injuries.1,24
Children with second degree burns present with severe pains and so the need for pain management in such patients as well as proper treatment to prevent shock from burns or infection should be taken care of properly.
There is need for a proper emergency service facility with blood transfusion center, trained personnel with emergency tray for venous cut down in case of shock and good fluid management as they all determine prognosis.
Apart from fluid, antibiotic, blood in the management of burns, there is room for less costly grafting techniques and open management of wounds as opposed to closed management in a dedicated burn centre as evidence has shown better outcome.1,24,59
2.4.3 Management of drowning
Studies all over the world showed that most lives are saved when by standers are good swimmers as lay or professional rescuers.167
Injuries arising from drowning occur because a person cannot breathe in oxygen with resultant poor supply to tissues and organs. When the person is eventually rescued, he might have stopped breathing and suffered brain damage. The mental status of the rescued person determine his/her survival.1,17,64
lxxi
The prognosis of drowning starts from the scene of injury. There is evidence that those who receive immediate help and resuscitation from bystanders have better survival rate.167
Immediate mouth to mouth resuscitation or cardiac message by bystanders is very important and so there is need to train people on steps in resuscitation and also functional health system where facilities for advanced life support and personnel are available because even in HIC the survival rate depends on interventions at the scene of drowning.1,167
There is also need to have facilities for long-term care and rehabilitation especially for children who survive with neurological brain damage as it is a challenge to the family, community and the nation.167There is also need for family support as the loss of a child is devastating to the family and the health care provider.1
2.4.4 Management of falls
Community based surveys from LMIC showed that most children with moderate or several injuries as a result of falls do not have access to medical care due to long distance to health facilities, poor road accessibility, poverty with inability to transport themselves, lack of awareness of the problem by the health caregiver for early interventioin.80,84,196
The Jiangxi studies concluded that most children who sustain fall related injuries were either alone or with another child at the time of injury or when adult care givers are around; they lack basic knowledge on first aid or find it difficult to locate health care facilities.80
Within the health facility, inability to recognize early features of intracranial haemorrhage compounded by inadequate facilities, poor air-way management, poor handling of stable fractures of the limbs or cervical spine when referring the child, inadequate acute and rehabilitative care also influence survival.1,80,84,196
Survey from the Islamic Republic of Iran reported that 40% of childhood fatalities from falls occurred within the pre-hospital setting, 30% within the emergency department and 30% in the hospital.196
lxxii 2.4.5 Management of poisoning
Prompt assessment of victims, diagnosis and treatment determine the survival and subsequent prognosis of the child which is better in places with poison control centres because of standard protocols available.1
The availability of health facilities, well trained personnel’s and access roads affects the outcome of poisoning. The rural areas and developing countries have a higher fatality rates because of poor health care system, infrastructures, and knowledge of toxicology regarding current management protocols in the care of the poisoned individual.1
The Tehran’s studies reported that trauma fatalities were 42% pre-hospital, 20% within the emergency department and 37% were hospital deaths. More than 80% of fatal poisoning and drowning occurred in pre-hospital setting and that 92% of burn related fatalities happened after hospital admission prompting the need for good emergency care.93
The management of poison entails immediate advice and first aid, prompt treatment and rehabilitation.
The acute management of poisoning involves;1,231
Removing the child from the source of poisoning
Assessing source or agent of poisoning, does, time of ingestion or inhalation, clinical state of the child.
Stabilizing the child which involves assessing the airway, breathing and the circulation.
Decontaminating the child to limit the extent of injury via topical decontamination for splashes, activated charcoal to absorb organic poisons, catharsis to increase gastric motility thereby expelling the agent, whole bowel irrigation, alkaline dieresis to enhance elimination, dialysis or use of antidotes like naloxone for opioids, atropine for organo-phosphorous pesticides and anti-venoms.
lxxiii
Providing supportive and rehabilitative care.
The functions of the poison control centres involve advising individuals and healthcare facilities, first aid care, referral of severe poisoning to appropriate facilities all aiming at decreasing morbidity and mortality.1
The poison control centre contributed significantly to the decrease fatality in HIC and are now being established in many LMIC.1,231
The establishment of poison control centres is a challenge to low income or developing countries because there need is not well understood, there is inadequate staff in most health care facilities, poor clinical and laboratory toxicology services for expert management of cases and poor communication network.232