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Tips & Tricks in Pediatric Emergency Medicine Kelly Black, MD, MSc.

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Presentation on theme: "Tips & Tricks in Pediatric Emergency Medicine Kelly Black, MD, MSc."— Presentation transcript:

1 Tips & Tricks in Pediatric Emergency Medicine Kelly Black, MD, MSc

2 I have no disclosures or conflicts of interest.

3 Children are NOT just little adults! Eat  food, drink  fluids, and breathe  air Behavior patterns make them more susceptible (hands in mouth, play in soil) Metabolism may be  /  capable of breaking down, inactivating or activating substances Body systems still developing Neurological, immunological, digestive, etc Vital signs vary by age Resp failure most common cause of cardiac arrest

4 You are not going to break the baby Don’t be scared of kids They aren’t made of glass They smell fear and feed off it (like dogs!) … you will scare the already frightened child & parents Undress kids – put them in gowns or diapers Don’t miss abusive signs Don’t miss key findings Find ways to interact Funny voices, faces, noises Singing Stickers

5 Lacerations – How am I going to fix THAT?

6 How would you repair these wounds?

7 Staples

8 Advantages: Quick Cheap Easy (relatively) Disadvantages: Painful Scary & noisy Have to return to have removed Is there an alternative???

9 Hair Apposition Technique (HAT)

10 Wound irrigation and exam Twist together strands of hair on one side of wound Do same on the other side of wound Interlock two hair bundles in 360-degree revolution. Do not tie a knot. Secure intertwined hair bundles with tissue adhesive Repeat as needed to close length of the laceration

11 Modified HAT Trick Published by Dr. John Fowler (Turkey, 2009, American Journal of Emergency Medicine) Uses hemastats to allow for instrument manipulation of hair bundles Allows provider to twist hair as short as 1 cm

12 HAT Trick Advantages: Less scary, no noise Less pain Faster Tweeze or comb out; no need to return Disadvantages: Takes a little more time Avoid glue inside wound

13 HAT Trick

14 Modified HAT Trick

15 How would you repair these wounds?

16 Laceration Repair Options Sutures – traditional approach Tissue Adhesive – Fast! Easy! Gravity is your friend Careful with eyes Can also use petroleum (Surgi-Lube) Careful with high tension – chins Not for mucosa Dermabond, Indermil, etc Steri-strips In addition to tissue adhesive for reinforcement Add benzoin to make stick longer

17 Tissue Adhesive

18 Tissue Adhesive + Surgical Strips + Benzoin Kids are way more active than us … protect the repair with reinforcement!

19 How would you repair this injury?

20 Nailbed Injuries Sutures Laceration Nail replacement What about tissue adhesive? Yes you can! For laceration For nail replacement Make sure to use a tourniquet … blood + glue = a mess!

21 Nailbed Injuries 40 consecutive patients Compared tissue adhesive vs. suture (6- 0 chromic) Time to repair: 9.5mins Dermabond 27.8 mins suture No statistical diff in cosmesis (MD or patient), function E.J. Strauss, W.M. Weil, C. Jordan, and N. Paksima, "A prospective, randomized, controlled trial of 2- octylcyanoacrylate versus suture repair for nail bed injuries.", The Journal of hand surgery, 2008.

22 Foreign Bodies - If it fits …

23 Foreign Bodies Where there is 1 there is good chance there is actually 2 or 3 or 4 …. Check both ears & nares Your first attempt is by far your best attempt so be fully prepared Restraint Nasal speculum Lighting Extraction device If you can’t get it out and not a critical object (button battery), send them to outpatient ENT

24 Kissing technique Often over-looked and under-valued … worth a try Easy to do, less scary and don’t need equipment Success rate 50% … if works avoids everything else! Positive-pressure technique Explain to parents: Have child blow nose (not usually successful due to age) Parent places mouth over child’s while occluding unaffected nostril Parent exhale into child’s mouth … FB shoot’s out of nostril (usually + snot … have a tissue ready)

25 Foreign Bodies

26 How am I going to get this kid to sit still for this?

27 Gentle Restraint Concepts Arms over head Superhero cape Burrito wrap

28 Arms over head Useful for suctioning and times you need head control Keeps head midline and controlled

29 Superhero Cape Restrains arms and hands Keeps arms and hands inside Burrito Wrap more effectively

30 Burrito Wrap Use a sheet Control arms, hands, legs, feet, etc Best to combine with superhero cape


32 Procedural Adjuncts

33 Intranasal medications Meds: Midazolam, lorazepam Fentanyl Naloxone & Flumazenil Why use these? Less invasive -- no IV needed Can quickly administer (burns, fractures, seizure) Tips Aim atomizer towards ear -- SPRAYS mucosa Max dose/absorption per nostril is 1 mL Can do both nares at once, two people

34 Intranasal Medication Doses DrugIndicationDoseMaximum Dose Concentration FentanylPain1.5 – 2 mcg/kg100 mcg50 mcg/mL MidazolamSeizures Anxiolysis 0.2 mg/kg 0.4 – 0.5 mg/kg 10 mg5 mg/mL LorazepamSeizures0.1 mg/kg4 mg2 mg/mL NaloxoneOpioid reversal0.1 mg/kg2 mg1 mg/mL FlumazenilBenzodiazepine0.01 mg/kg0.2 mg single dose, 1 mg or 0.95 mg/kg cumulative dose 0.1 mg/mL

35 Be Kind … Treat Pain (and fever) Topical anesthesia: LET Apply to open wound 20-30 mins & will blanch white Apply pressure if able (ex. head band with coban) May not need injectable lidocaine LMX – 30-40 mins; LP, delayed PIV starts J-tip – PIV starts, nerve blocks, LP Oral analgesia Acetaminophen and/or ibuprofen (Remember the power of oral antipyretics …  HR,  RR,  fussiness, calm everyone!)

36 Jtips What is is? Needleless delivery system using compressed carbon dioxide with buffered 1% lidocaine What is the effect? Almost immediate (30-60 sec), lasts about 30 mins Why use this?  pain, anxiety, and detrimental impact on development and future pain  success for attempts and future compliance

37 Jtips Contraindications: Sensitivity to lidocaine Pre-term infants or neonates (<1kg or <38 wks) Administration over infected skin Thrombocytopenia (< 20K) or bleeding disorders On chemo or anticoagulation Tips: Warn child of noise (“pop can”) Press firmly (sprays) Pull to side of vein if for PIV start (bleeding) NOT just for PIV starts (digital blocks, LPs, etc)

38 J-tips

39 Other ways to be less invasive …

40 Albuterol puffs vs neb Problem with MDIs: Requires more patient coordination & education to use “They don’t work” -- Many patients not getting same improvement are not using Spacer or MDI is empty Problem with Nebs: Requires someone to hold the “mystical smoke” near the patient’s face “Mystical smoke” is difficult to target Home neb machines filthy & disgusting Home neb machines not very portable … Grandma’s house, school, vacation?

41 Albuterol puffs vs neb MDI’s! MDI’s! MDI’s! Studies show equal efficacy for bronchodilator delivery Some even show may be superior --  LOS,  tachycardia & more cost-effective “Mystical smoke” inhaled by everyone else more than the patient MDI use in the ED: At least as, if not more, efficacious as nebs Less time to administer Educational opportunity!

42 Digital Block … single injection Single, SQ, volar-approach digital block Traditional method: 2 injections at finger base Inject at midpoint of crease where finger joins palm (volar side) Inject 2-3 mL SQ, anesthetic deposit on top of tendon sheath & infiltrate nerves

43 Vomiting Illness The beauty of ODT ondansetron – ZORT Give ODT ondansetron (Z), wait 20 mins, then oral rehydration therapy (ORT) Small, slow amounts of PO fluids (ex. 5 mL q5 mins) Popsicle therapy works … especially for Mom & Dad! PROs of ORT (oral rehydration therapy): Can be used for mild to moderate dehydration No need for IV Less expensive Lower hospitalizations and shorter LOS Can be taught and DONE AT HOME!

44 Vomiting Illness There is no such thing as a “PO Challenge” when it comes to gastroenteritis in children Do not try to demonstrate child is safe to go home because they didn’t vomit Instead, teach that vomit and diarrhea with continue and ORT can be performed at home to maintain hydration Give appropriate anticipatory guidance and teaching

45 Apps that may help you with kids Ballonimals $1.99 on iphone, $2.99 bundle (+ balloonimal babies) Child blows at mouthpiece of iPhone  inflates balloon Shaking iPhone  convert balloon into T-Rex dinosaur Touching screen animates 3D dinosaur Touching air pump icon will pop balloon

46 Apps that may help you with kids Candle flame Free iphone apps “Blow out the candle” Distraction Assist with pulm exam Eye Handbook Free iphone app Pediatric fixation animation targets – dancing cartoon animal with distacting noises Distraction!

47 Questions?

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