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a_ARTS > 11/16- Pediatric ER Procedures > Flashcards

11/16- Pediatric ER Procedures Flashcards

1
Q

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?

A

Some kind of anesthesia for his pain

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2
Q

What are the different types of anesthesia?

A
  • 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
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3
Q

What is the most commonly used type of anesthesia?

A

Direct infiltration: injection directly into tissue

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4
Q

What are types of local anesthetics?

A
  • 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
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5
Q

What are indications for local anesthesia of the following types:

  • Direct wound infiltration
  • Field block
  • Topical anesthetics
A

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
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6
Q

What are contraindications to local anesthesia?

A
  • Bupivacaine: age under 12 years
  • Epinephrine and LET: avoid the “nose, ‘hose’, ears, and toes”
  • EMLA: skin not intact
  • All topicals: avoid the eyes
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7
Q

What are complications for local anesthesia?

A
  • 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)
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8
Q

What supplies do you need for local anesthesia?

A
  • 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
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9
Q

How to modify local anesthetics for certain goals?

  • Minimize bleeding
  • Increase duration of action
A

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)
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10
Q

How to modify local anesthetics for certain goals: minimize pain?

A
  • 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!
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11
Q

What are common nerve blocks?

A
  • Digital
  • Auricular
  • Infraorbital
  • Mental
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12
Q

Where is the digital nerve?

A
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13
Q

Describe nerves around the ear

A
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14
Q

Where to inject for infraorbital nerve block?

A
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15
Q

Where to inject for mental nerve block (upper)?

A
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16
Q

Where to inject for mental nerve block (lower)?

A
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17
Q

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?
A

Incision and drainage of abscess

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18
Q

What are indications for I/D (incision/drainage) of abscesses?

A
  • Acute, superficial, localized cutaneous abscess
  • Fluctuant mass with high likelihood of underlying purulent material
  • Differentiating from just cellulitis may be helped with ultrasound
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19
Q

What are contra-indications for I/D of abscesses?

A
  • 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
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20
Q

What are complications of I/Ds of abscesses?

A
  • Scar formation
  • Abnormal wound healing
  • Bleeding
  • Bacteremia
  • Damage to underlying structures
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21
Q

What are supplies needed to perform incision and drainage?

A
  • Scalpel
  • Blunt hemostat
  • Forceps
  • 2x2 gauze
  • Iodine swab
  • Sterile drape
22
Q

Describe the I/D process of abscess

A
  • 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
23
Q

What is aftercare for I/D for abscess?

A
  • Antibiotics are controversial
  • If under 5 cm, definitive care is drainage
  • Change packing in 24-48 hrs
  • Warm soaks QID (3-4x/day)
24
Q

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…
A
  • 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
25
Q

What are indications for a lumbar puncture?

A
  • Suspected CNS infection
  • Suspected subarachnoid hemorrhage
  • Evaluation of other suspected CNS diseases (pseudotumor cerebri, Guillain-Barre, MS)
26
Q

What are C/Is for a lumbar puncture?

A
  • Infection adjacent to proposed LP site
  • Cardiorespiratory instability of patient
  • Uncorrected, severe coagulopathy (plt < 100)
  • Spinal cord trauma/compression
  • Signs of progressive cerebral herniation
27
Q

What are complications of a lumbar puncture?

A
  • 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??
28
Q

What supplies do you need for a lumbar puncture?

A
  • 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
29
Q

What needles to use for lumbar punctures in what populations?

A
30
Q

Describe best position to collect lumbar puncture

A
  • Lateral recumbent
  • Sitting
31
Q

Describe the anatomy of where you collect a lumbar puncture

A
  • Taken at L4-L5 interspace
  • Taken between ligamentum flavum and dura/arachnoid layes??
32
Q

Describe lumbar puncture troubleshooting for success

A
  • 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
33
Q

What if your tap comes out bloody?

A
  • Microscopy may not be helpful…
  • Can still send for culture
34
Q

What are routine ordering tests with lumbar puncture?

A

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)
35
Q

Case 4)

  • 8 y/o boy was running, when a branch hit him in his right eye What needs to be done?
A

Fluorescein Exam

36
Q

What are indications for fluorescein exam?

  • Contraindications?
  • Complications?
A
  • Indications: suspected corneal abrasion
  • C/I: none
  • Complications: orange staining of clothing/sheets
37
Q

What are supplies needed for fluorescein exam?

A
  • Fluorescein strip
  • Proparacaine and/or saline eye drops
  • Wood’s lamp
38
Q

What is seen here?

A

Positive fluorescein test

  • Depending upon size and location, probably get some medicated ointment and follow up with optho
39
Q

Case 5)

  • A 3 y/o boy presents after putting a round metal object in his nose
  • What needs to be done?
A

Foreign body removal

40
Q

What are indications for foreign body removal?

  • Contraindications
A

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
41
Q

What are complications of foreign body removal from the nose?

A
  • Bleeding and other local trauma to nasal mucosa
  • Cribriform plate puncture (if medial/superior to the middle turbinate)
  • Foreign body aspiration
42
Q

What supplies are needed for foreign body removal from the nose?

A
  • Head light or surgical lamp
  • Nasal speculum
  • 4% lidocaine
  • 0.25% Neosynephrine
  • Suction
  • Alligator forceps or Katz extractor

OR

  • Parent’s Kiss technique
43
Q

Describe the process of removing foreign body from the nose?

A
  • Position; visualize with nasal speculum
  • Anesthetize (4% topical lidocaine) +/- sedation
  • Topical vasoconstrictor (Neosynephrine) for significant swelling
  • Remove with alligator forceps or Katz extractor
44
Q

Case 6)

  • 10 yo girl woke up with buzzing sensation in her ear
  • On exam you see the following
  • What needs to be done
A

Foreign body removal from the ears

45
Q

What are indications and contraindications for foreign body removal from the ear?

A

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
46
Q

What are complications of foreign body removal from ear?

A
  • Bleeding
  • TM perforation
  • Otitis externa
47
Q

What supplies are needed for foreign body removal from the ear?

A
  • 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
48
Q

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
A

Reduction of radial head subluxation (nursemaid’s elbow)

49
Q

What are indications and contraindications for reduction of radial head subluxation?

A

Indications: history/exam consistent with RHS

Contraindications: suspected fracture

  • Swelling, deformity, bruising, or neurovascular compromise
50
Q

What are complications of reduction of radial head subluxation?

A

Exacerbation of a fracture, if present

51
Q

What are supplies needed for reduction of radial head subluxation?

A

None

52
Q

Describe the process for reduction of radial head subluxation?

A
  • Hyperpronation (95% success)
  • Suppinate/flex (77% success)

a_ARTS (17 decks)

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