PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "procedures"

Tips and Tricks

Success rates in infant lumbar punctures may be declining as we do fewer and fewer (doing fewer is a good thing, except that we get less experience). One thing that can improve success is early stylet removal. The stylet is kept in when entering the skin in order to avoid the very rare complication of intraspinal epidermoid tumors. However, once the needle is past the epidermis and dermis, such that a plug of skin tissue cannot be cored out by the hollow needle and deposited into the spinal canal, the stylet can be removed. Here are two excellent FOAMed discussions of this practice and the advantages: http://pemcincinnati.com/blog/wwdwwd-early-stylet-removal-lp/ and https://pedemmorsels.com/spinal-needle-stylet/
There are several techniques for removing a ring that is stuck on a patient’s finger, starting with the simplest – using ring cutters to cut it off. However, if the patient doesn’t want the ring destroyed, the string technique has been advocated, where a string is wrapped around the finger to compress the edema, then passed under the ring and unwound for removal. An oxygen mask strap works well for this purpose because of its elasticity and flatness; check out this AliEM trick of the trade post https://www.aliem.com/2012/08/trick-of-trade-ring-removal-using/. Also, this site provides a nice overview of the numerous methods https://aneskey.com/ring-removal/. Remember that tungsten and ceramic rings are usually hard to cut, but easy to break using vice or locking pliers.
Nothing slows down the ED flow like waiting for the urine flow of an infant or toddler. Whether or not to screen for UTI with a clean catch urine vs obtain a catheterized specimen will be left for another discussion, but here are some of the latest techniques described for obtaining clean catch specimens. (For all, clean genital area thoroughly first) "CCU" procedure, first described by Herreros Fernandez et al, Arch Dis Child 2013;98:27, 80 infants aged < 30 days. Patient held under armpits with legs dangling in upright position. Suprapubic area gently tapped at 100 taps/minute x 30 seconds, followed by light circular massage of the lower back x 30 seconds. Repeat these maneuvers until urine collected. Successful in 86% of the infants with median time to collection 45 seconds. Labrosse et al, Pediatrics 2016;138(3):320160573 studied this CCU method with the addition of another person flexing the hips of female children, 126 infants < 6 months old. CCU method successful in providing urine sample within 300 seconds in 49%, median time 45 seconds. More successful in < 3 months old than 3-6 months old. "Quick-Wee" method, Kaufman et al, BMJ 2017;357:j1341, 354 infants aged 1-12mos With patient supine, suprapubic skin was rubbed with gauze soaked in cold saline. 31% voided within 5 minutes using Quick-Wee vs. 12% in the standard collection group. Finally, Naimer in Pediatr Emerg Care 2017;33:446 describes cutting a slit in an infant's diaper to push the urine collection bag through when obtaining a bag urine. This both helps to secure the bag and allows parents and nurses to see when the specimen has been obtained.
Your local hospital cafeteria can be a useful resource in managing your PED patients:
  1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
  2. A mayonnaise packet provides useful lubricant for removing a tight ring
  3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
  4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants
Know of any more? Comment below!
Having trouble with bag valve mask ventilation? Don't forget to use adjunctive airways - nasopharyngeal for conscious patients, oropharyngeal for unconscious. Reuben Strayer's great video here advocates placing 2 nasal airways and an oral airway, then bagging over those, for the difficult to bag patient. You can also place an ETT adaptor (pull the adaptor off the tube) into a nasal airway and bag the nasal airway directly - see more information here. Don't forget, nasal airways are measured from the nostril to the tragus of the ear, and oral airways are measured from the center of the mouth to the angle of the jaw.
Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885
Thanks to Tim Horeczko pemplaybook.org for tube-tape-tap mnemonic Peds Sizing  
We all know the importance of lining up the two sides of a laceration that goes through the vermillion border of a lip laceration. Injecting lidocaine or swelling from the trauma itself can make this difficult. Use a skin marker to outline the the vermillion border on each side, making this easier. Vermillion border closing the gap This photo comes from this great tutorial on Closing the Gap For lip lacerations requiring repair beyond simple alignment, consult a plastic surgeon. Here is an interesting discussion on Plastic Surgery Key
The Katz extractor is a great tool for removing nasal foreign bodies, as shown on the video here (I have no financial interests in this product). But, if you don't have one available, get a Fogarty cardiac embolectomy catheter from the O.R., and this will do nicely as well. For many many tips and tricks on removing foreign bodies in the head and neck, go to PEMplaybook
For minor procedures in the PED, analgesia, anxiolysis, and distraction are the most important therapies to promote cooperation and procedural success. See our algorithm for procedural pain here. But sometimes, even with all of those, physical restraint is needed. Most PEM practitioners know how to wrap a child up using a simple bedsheet folded lengthwise twice, and then wrapped over one arm, behind the back, and over the other arm, and then around the child as seen here. Another technique if you have a pillowcase is to put both arms behind the child into a pillowcase and then lay the child down onto the pillowcase, thus restraining the arms (see picture below). (This technique was published under the colorful name "Superhero Cape Burrito" here). Finally, a c-collar can be useful to immobilize the head for face and scalp laceration repairs. pillowcase-restraint
Mucosal atomizer devices improve administration of intranasal medications. Intranasal fentanyl 1.5 mcg/kg is a great way to give stronger pain medication (eg for fractures) without placing an IV. Intranasal midazolam 0.2 mg/kg (use concentrated 5mg/mL form to keep total volume < 1mL per nostril) can be used to treat active seizures when no IV access is yet obtained, or as an anxiolytic for procedures. Intranasal naloxone at a standard dose of 4 mg is being provided to opiate addicts to use in case of overdose. A commercial device is available, but currently some lots are being recalled (check here for recalled lots), or you may simply not have one in stock. Here's how to make an improvised atomizer courtesy of Faisal Alghamdi of KFMC Riyadh. Hook up a 3 way stopcock with the lever turned so that all 3 ports are open to 1) a 14 or 16 gauge angiocath, 2) a syringe with the medication you wish to deliver, and 3) oxygen tubing. Hook the other end of the oxygen tubing up to oxygen and turn up to 5-10 L/min. Place the angiocath in the nostril and gently & slowly depress the plunger of the medication. See picture and video below. img_1123 Click here to see a video and compare to commercial device here
You're seeing a 5 day old with a fever of 39. Attempts to get IV access have been unsuccessful. The child is alert and not toxic appearing, but you'd like to get empiric antibiotics started within the first hour of evaluation. What are your options other than drilling with an IO or embarking on a potentially long sweaty frustrating attempt at a central line in a neonate? An ultrasound-guided peripheral line is one possibility if you have the skills. Another vascular access method to keep in mind is the umbilical venous line - the umbilical vein can stay patent up to 7-10 days of life! Soak the dry cord in saline soaked gauze to soften it, use a scalpel to cut straight across at 1-2cm from the base, look for the single large vein, insert a pre-flushed catheter with gentle pressure into the vein while pulling back on a syringe until you see a flash of blood. For more info: https://blogs.brown.edu/emergency-medicine-residency/emergent-umbilical-venous-catheter-uvc-placement/ The "Fast-cath" technique advocates using a 14 gauge angiocath http://www.emsworld.com/article/10852257/paramedic-umbilical-vein-catheterization-for-newborns Find resources for born out of asepsis babies on our algorithms page, including how to make umbilical venous catheter mini kits to keep in your ED. http://pemsource.org/algorithms/boa-newly-born/
Check out these cuties that CHOC PED physician and former Harbor PEM fellow Seth Brindis makes! See below for step-by-step instructions and more ideas for toys to make with medical supplies. Tongue Depressor Puppets Here are instructions put together by Seth, and a video of them in action. And here are some more ideas for toys to make in the PED (thanks to former Harbor PEM fellow Casey Buitenhuys for the glowstick idea): make-your-own-toys
Use a sterile saline respiratory ampule: wet the fluorescein strip with the saline, squeeze out half of the saline, then suck the yellow fluorescein liquid back up into the ampule. Now you can use the ampule as an eyedropper. For uncooperative kids, lay them supine and squeeze the liquid into the medial corner of the closed eye - when they open their eyes it will run into the eye. Respiratory Ampules (Amazon.com) For additional methods, see AliEM's great tricks of the trade post at: https://www.aliem.com/2015/tricks-of-the-trade-fluorescein-eye/
Cut a narrow caliber ETT short to create a semi-rigid suction catheter for foreign body removal of the nose or ears.  (From EM News September 2009, Tricks of the Trade: An Improvised, Semi-Rigid, Nasal/Aural Suction Catheter, by Timothy McGuirk DO)
For a forhead laceration, place gauze over patient's eye and hairline, cut a hole in center of a large tegaderm, peel and stick with the laceration positioned in the middle of the hole. Now you can use tissue adhesive to close the laceration without worrying about the adhesive running into the patient's eye, hair, or down the face.
Use a laryngoscope upside down as a tongue blade, or use a self-lighting pelvic exam speculum (remove top half of the speculum)

Conundrums

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old with 1 day of limp and now, refusal to bear weight. He is afebrile. On exam, his hip is irritable to passive external and internal rotation. He holds his hip slightly externally rotated. His CBC WBC is 8,400 with 50% neutrophils, and his ESR is 20. His plain films are normal. He has reliable parents and an assigned pediatrician who can see him the next day. [poll id="25"]
You are about to incise and drain a relatively small simple abscess in a healthy child. (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="17"]
You are seeing a 4 year old with a deep cheek laceration with irregular margins, under some tension. The parents express concerns about scarring, and they are also concerned that their child will definitely not be able to stay still for repair or for suture removal. Plastic surgery is unavailable, and the parents are amenable to having you repair the laceration with procedural sedation. Forheadlac (Source: Closing the Gap https://lacerationrepair.com) [poll id="14"]
3 week old infant is brought in with fever of 38.5. The baby is well appearing and does not have any high risk factors in the birth history. You plan to get urine, blood, and CSF cultures and give empiric IV antibiotics. [poll id="8"]

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A 2 month old ex-30 week premie just discharged from the NICU comes in with respiratory distress and hypoxia. You determine that the patient needs to be intubated. The baby’s weight at discharge was 2.5 kg. What size ETT should you use? A. 2.5 uncuffed B. 3.0 uncuffed C. 3.0 cuffed D. 3.5 uncuffed E. 3.5 cuffed Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here

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