11/16- Pediatric ER Procedures Flashcards
Case 1)
- A 13 y/o boy caught his finger in a door
- On exam, bone is exposed, and plastics has been called
What do you do?
Some kind of anesthesia for his pain
What are the different types of anesthesia?
- Topical
- Direct infiltration: injection directly into tissue
- Parallel margin infiltration (field block)
- Injection into adjacent tracts parallel to the wound edge : interrupts nerve conduction (site -> CNS)
- Nerve blocks
- IV/IM/PO pain meds
- Moderate sedation/general anesthesia
What is the most commonly used type of anesthesia?
Direct infiltration: injection directly into tissue
What are types of local anesthetics?
- Aminoesters (procaine, cocaine, chloroprocaine, tetracaine)
- Aminoamides (lidocaine, bupivicaine, prilocaine, mepivacaine, etidocaine)
-
Topical forms of lidocaine:
- LET (lidocaine, epinephrine, tetracaine)
- EMLA (eutectic mixture of local anesthetics: lidocaine and prilocaine)
- ELA-Max (lidocaine)
- Ethyl chloride vapocoolant spray
What are indications for local anesthesia of the following types:
- Direct wound infiltration
- Field block
- Topical anesthetics
Direct wound infiltration
- Most wounds and lacerations
Field block
- Areas of inflammation (abscesses) or gross contamination
- Preserved wound architecture desired
Topical anesthetics
- Prior to wound infiltration (LET)
- Prior to LP (EMLA, ELA-Max)
- Prior to vein cannulation
What are contraindications to local anesthesia?
- Bupivacaine: age under 12 years
- Epinephrine and LET: avoid the “nose, ‘hose’, ears, and toes”
- EMLA: skin not intact
- All topicals: avoid the eyes
What are complications for local anesthesia?
- Nervous system toxicity
- Irreversible heart block (bupivacaine)
- Arrhythmia
- Allergic reactions (rare)
- Tissue injury with injection (nerve, ischemia from epi or compartment syndrome)
- Infection
- Bleeding
- Methemoglobinemia
- Skin discoloration or irritation (topicals)
What supplies do you need for local anesthesia?
- Cottonball (if using LET)
- Tegaderm (if using EMLA or ELA-Max) 3, 5, or 10 ml syringe
- 18 g needle to draw up medication (use filter needle for broken glass vials)
- 27 g, 1 ¼ inch needle for injection
- NaHCO3 (premixed in TCH EC pharmacy)
- Lidocaine +/- Epinephrine and/or Bupivacaine
How to modify local anesthetics for certain goals?
- Minimize bleeding
- Increase duration of action
Minimize bleeding:
- Add epinephrine (if not contraindicated)
Increase duration of action:
- Mix with bupivacaine (4-8 hrs vs 1-2 hrs)
- Add epinephrine (1-3 hrs vs 1-2 hrs)
How to modify local anesthetics for certain goals: minimize pain?
- Buffer with NaHCO3 -> also speeds onset of action; Lido:NaHCO3 9:1 ratio
- Use the smallest needle (27 g, 1 ¼ inch)
- Sensory distraction (local and behavioral)
- Child Life
- Warm the anesthetic to room temperature
- Inject slowly
- Test before starting the procedure
- Don’t show them the needle!
What are common nerve blocks?
- Digital
- Auricular
- Infraorbital
- Mental
Where is the digital nerve?
Describe nerves around the ear
Where to inject for infraorbital nerve block?
Where to inject for mental nerve block (upper)?
Where to inject for mental nerve block (lower)?
Case 2)
- A 5 y/o boy presents with pain (dolor), redness (rubor), warmth (calor), and swelling (tumor) on his back
- What is the treatment and how will you do it?
Incision and drainage of abscess
What are indications for I/D (incision/drainage) of abscesses?
- Acute, superficial, localized cutaneous abscess
- Fluctuant mass with high likelihood of underlying purulent material
- Differentiating from just cellulitis may be helped with ultrasound
What are contra-indications for I/D of abscesses?
- Extension to deeper structures (e.g. rectum, abdomen, labia, neck) -> consult a surgeon
- Chronic/recurrent abscesses in the same location -> consult a surgeon
- Cellulitis without abscess formatio
- Differential of apparent “abscess”
- Branchial cleft anomaly
- Cystic hygroma
- Scrofula
- Kerion
- Autoimmune inflammatory process
What are complications of I/Ds of abscesses?
- Scar formation
- Abnormal wound healing
- Bleeding
- Bacteremia
- Damage to underlying structures
What are supplies needed to perform incision and drainage?
- Scalpel
- Blunt hemostat
- Forceps
- 2x2 gauze
- Iodine swab
- Sterile drape
Describe the I/D process of abscess
- Anesthetize +/- Procedural Sedation
- Regional block
- Superficially over incision site
- Prep/Drape
- Incise (make it long enough) and obtain culture
- Break loculations in 360’ direction and express pus
- Consider drain
- Irrigate
- Fill with iodoform gauze
- Cover with sterile dressing
What is aftercare for I/D for abscess?
- Antibiotics are controversial
- If under 5 cm, definitive care is drainage
- Change packing in 24-48 hrs
- Warm soaks QID (3-4x/day)
Case 3)
- A 2 week old girl presents with a temperature of 101 F
- CBC, UA, and cultures are sent
- The patient also needs an…
- We get worried about temp > 100.4’F in babies
- Need lumbar puncture
- Even if no seizure, any fever > 100.4’F requires full sepsis eval, including lumbar puncture
What are indications for a lumbar puncture?
- Suspected CNS infection
- Suspected subarachnoid hemorrhage
- Evaluation of other suspected CNS diseases (pseudotumor cerebri, Guillain-Barre, MS)
What are C/Is for a lumbar puncture?
- Infection adjacent to proposed LP site
- Cardiorespiratory instability of patient
- Uncorrected, severe coagulopathy (plt < 100)
- Spinal cord trauma/compression
- Signs of progressive cerebral herniation
What are complications of a lumbar puncture?
- Headache and back pain (10-70%)
- Infection (spinal abscess, meningitis, cellulitis)
- Bleeding (spinal hematoma)
- Cerebral herniatio
- Vertigo, tinnitus (reduced endolymph volume)
- Damage to adjacent structures
- Hypoxemia (secondary to positioning in infants)
- Nerve damage??
What supplies do you need for a lumbar puncture?
- Analgesia plan (sucrose, EMLA, lidocaine, child life…)
- Sterile gloves
- Betadine solution
- LP tray
- Extra spinal needle(s) Infant tray has 3CSF collection tubes and neither manometer, nor flexible tube nor stopcock
- Neither tray has Betadine or sterile glove and you often need extra buffered Lidocaine for older children and teens
What needles to use for lumbar punctures in what populations?
Describe best position to collect lumbar puncture
- Lateral recumbent
- Sitting
Describe the anatomy of where you collect a lumbar puncture
- Taken at L4-L5 interspace
- Taken between ligamentum flavum and dura/arachnoid layes??
Describe lumbar puncture troubleshooting for success
- Direct needle towards umbilicus
- Guide needle with your thumb
- OK to remove stylet once through sub Q tissue
- Once getting fluid, let go of the needle
What if your tap comes out bloody?
- Microscopy may not be helpful…
- Can still send for culture
What are routine ordering tests with lumbar puncture?
Routine tests (1 mL each)
- Gram stain and culture
- Cell count (clearest tube)
- Glucose and protein
If diagnosis is unclear:
- Collect extra CSF place in bag and then place this bag in ice and “hold in virology” (must be separate tube)
Case 4)
- 8 y/o boy was running, when a branch hit him in his right eye What needs to be done?
Fluorescein Exam
What are indications for fluorescein exam?
- Contraindications?
- Complications?
- Indications: suspected corneal abrasion
- C/I: none
- Complications: orange staining of clothing/sheets
What are supplies needed for fluorescein exam?
- Fluorescein strip
- Proparacaine and/or saline eye drops
- Wood’s lamp
What is seen here?
Positive fluorescein test
- Depending upon size and location, probably get some medicated ointment and follow up with optho
Case 5)
- A 3 y/o boy presents after putting a round metal object in his nose
- What needs to be done?
Foreign body removal
What are indications for foreign body removal?
- Contraindications
Indications:
- Suspected foreign body (unilateral nasal discharge, recurrent epistaxis, halitosis, seen placing button in nose)
- Button batteries (immediate removal STAT ENT if unable to remove)
Contraindications for removal:
- Unsuccessful attempt in a fearful/struggling child, despite behavior modification
What are complications of foreign body removal from the nose?
- Bleeding and other local trauma to nasal mucosa
- Cribriform plate puncture (if medial/superior to the middle turbinate)
- Foreign body aspiration
What supplies are needed for foreign body removal from the nose?
- Head light or surgical lamp
- Nasal speculum
- 4% lidocaine
- 0.25% Neosynephrine
- Suction
- Alligator forceps or Katz extractor
OR
- Parent’s Kiss technique
Describe the process of removing foreign body from the nose?
- Position; visualize with nasal speculum
- Anesthetize (4% topical lidocaine) +/- sedation
- Topical vasoconstrictor (Neosynephrine) for significant swelling
- Remove with alligator forceps or Katz extractor
Case 6)
- 10 yo girl woke up with buzzing sensation in her ear
- On exam you see the following
- What needs to be done
Foreign body removal from the ears
What are indications and contraindications for foreign body removal from the ear?
Indications
- Visualized foreign body in the external auditory canal
- Button batteries and patients with significant discomfort (immediate removal)
Contraindications
- Unsuccessful attempt in a fearful/struggling child, despite behavior modification
What are complications of foreign body removal from ear?
- Bleeding
- TM perforation
- Otitis externa
What supplies are needed for foreign body removal from the ear?
- Ear speculum
- 20 ml syringe with butterfly tubing (needle cut off)
- Warm saline for irrigation
- Alligator forceps
- Ear loop
- Mineral oil or viscous lidocaine for insects
- Need to kill insect before trying to remove
- Lidocaine in ear will kill the insect
Case 7)
- 2 yo went to Galveston and dad was swinging him by the arms at the beach
- He presents with refusal to move his left elbow
- What needs to be done
Reduction of radial head subluxation (nursemaid’s elbow)
What are indications and contraindications for reduction of radial head subluxation?
Indications: history/exam consistent with RHS
Contraindications: suspected fracture
- Swelling, deformity, bruising, or neurovascular compromise
What are complications of reduction of radial head subluxation?
Exacerbation of a fracture, if present
What are supplies needed for reduction of radial head subluxation?
None
Describe the process for reduction of radial head subluxation?
- Hyperpronation (95% success)
- Suppinate/flex (77% success)
