Pediatric Office Based Procedures

Pediatric Office Based ProceduresPediatric Office Based Procedures Ellen Szydlowski, MD Assistant Professor of Pediatrics Director of Procedural Education Division of Emergency Medicine Children’s Hospital of Philadelphia
© 2020 by Ellen Szydlowski
Faculty Disclosure It is the policy of the Intensive Osteopathic Update (IOU) organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.
Learning Objectives
• Recognize the unique pediatric considerations for any office procedure
• Describe the various techniques that can be used to remove a foreign body from the ears and nose
• Perform simple finger procedures such as paronychia drainage and ring removal
Outline
• Nose • Ear • Earring
• Subungal hematoma • Paronychia • Ring removal • Hair tourniquet
Pediatric Considerations
• Non-pharmacologic: guided imagery/relaxation, videos, aromatherapy, focused breathing, sheet to hide, positioning for comfort
• LET/Lidocaine • Midazolam
• PO: 0.25-0.5 mg/kg; max 15 mg. Onset 10-15 minutes • IN: 0.4 mg/kg; max 10 mg; Peak 10 minutes
• Infants (Birth – 12 mo) • Fear of separation from parents • Maximize parental involvement and assess parents coping mechanisms • Parents can hold their hand, or participate in comfort positioning • Pacifiers can be soothing and calming • Light up toys, soft music, singing
Rollins, J. A. Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Pro- Ed, Inc, 2005.
• Toddlers (12 mo- 36 mo) • Stranger anxiety; short attention spans • Supine position feel vulnerable and scary • Encourage parental participation • Offer choices when possible • Provide simple explanations • Allow for motor activity – can include touching medical equipment • Expect treatment to be resisted • Comfort positioning, light up toys, singing, bubbles, videos, encouraging
statement
• Preschool (3yo-5yo) • Limited concept of time “This will take less time than singing the
ABCs” • Fantasy/magical thinking • Encourage parental participation • Offer choices when possible • Reinforce that doctor’s office/procedures are not punishments • Tell, show, do (stuffed animal, doll, caregiver) • Be aware of wording (stick, burn, stitches, go to sleep) • Comfort positioning, singing, bubbles, videos, encouraging
statement, humor/jokes
• School Aged (5yo-12 yo) • Increased participation in self care • Fears pain/death/bodily injury • Offer choices when possible • Encourage child participation in care/give specific tasks • Respect child’s modesty • Humor/jokes, encouraging statements, deep breathing, videos/games, ask about
hobbies • Adolescent (12yo-18yo)
• Concerned about self esteem and privacy • Involve adolescent in care and decision • Humor/jokes, encouraging statements, deep breathing, videos, guided imagery
You put that where??...Nasal FB
• Usually on floor near inferior turbinate or anterior to middle turbinate
• ENT consult: button batteries, paired disk magnets with septal injury, posterior FB
National Battery Ingestion Hotline: 800-498-8666
Nasal Foreign Body
• Positive Pressure • Good for smooth or soft large objects that occlude anterior nasal cavity • Occlude other nares and blow nose (>3 yo) • “Parent’s Kiss:” Occlude other nares, parents firmly seal their mouth over the
child's mouth and give a short, sharp puff of air into the child's mouth. Or BVM
Backlin SA. Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med. 1995; 25 (4): 554
Nasal Foreign Body
Nasal Foreign Body
• Materials: Suction to remove secretions Light source (headlamp) Nasal speculum Afrin Alligator Forceps Katz Extractor 8-10 Fr Foley Catheter with 5 cc syringe
Nasal Foreign Body
• Positioning: • In cooperative patient: sit up, push tip of nose up • Other options:
Nasal Foreign Body
• Afrin 5 min prior if there is significant edema • Non-occlusive compressible FB (foam, tissue)
alligator forceps
Katz extractor
Ear FB: External Auditory Canal
• ENT consult: button batteries, FB against TM, FB with TM rupture • Most lodged at narrow junction of cartilaginous and bony portions of
the EAC
• Positioning:
Brown JC, Klein EJ. The “Superhero Cape Burrito”: A Simple and Comfortable Method of Short-term Procedural Restraint. The Journal of Emergency Medicine, Volume 41, Issue 1, 2011, 74-76.
Ear FB: EAC
• Irrigation: small inorganic objects or insects. NOT for pts with tympanostomy tubes, vegetable material or button batteries
• Supine position, affected ear up or to the side or upright • Mineral oil or 1% lidocaine x 15 min to kill bugs • Plastic butterfly needle tubing or 14- to 16- gauge plastic intravenous catheter and
irrigate with warm water (insert ~1-1.5 cm into EAC) • Direct stream to posterior and superior margin of EAC
Ear FB: EAC
• Instrumentation: • Papoose, affected ear up • Soft object or insects: mini or micro alligator forceps (3-4mm) • Round objects: right angle hook or angled cerumen curette • Mobile round FB: suction
Ear FB: EAC
• Cooperative patients: Can try dermabond on end of angiocath
• Super glue, chewing gum and Styrofoam balls can be debonded or dissolved with acetone (soaked cotton ball applied x 10 min)
• EAC abrasions: ofloxicin gtts Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol. 1995; 109 (12): 1219.
Ear FB: Embedded Earring
Ear FB: Embedded Earring
• Back of earring embedded, front visible: Push posteriorly until back visible; if unable to push through make small posterior incision over piercing site
• Front of earring embedded, back visible: Push anteriorly until visible; otherwise posterior incision and pull through
• Both front and back embedded: Make small posterior incision • Topical abx
Fish hook Removal
• Most fish hooks have a barb at the distal end that is set into the tissue and prevents it from being backed out of the skin. Some hooks also have additional prominences on the shank itself.
Fish hook Removal
• Using wire cutters, remove fishing line, lures, weights, and any other material attached to the embedded hook
• Clean with betadine • Local infiltration with lidocaine
Fish hook Removal – Push Through Technique
• Equipment: Eye protection, hemostat, wire cutters
• Anesthetize the area where the hook will come out
• Use hemostat to grab distal end and advance fish hook until barb is through the skin
• If one barb, use wire cutters to cut the hook proximal to barb and back the hook out of the skin
• If multiple barbs, cut proximal (non-barb) end and using the hemostats on the distal end pull the entire hook through the new hole
Fish hook Removal – Push Through Technique
Fish hook Removal – String Technique
• Equipment: Eye protection, string or 3-0 silk sutures
• Loop string around belly of fish hook; the ends should be wrapped around clinicians index finger
• Exert downward pressure on the shank to disengage the barb
• Using a quick motion, pull parallel to the barbed tip with the string
• Be careful as the fish hook can be propelled out rapidly!
Fish hook Removal
immunocompromised. • Review Tetanus vaccination with family.
Finger Procedures
• Subungal hematomas
• Injury to distal phalanx causing bleeding of the nail bed
• Pain is pressure in a contained space pressing against nerve fibers
• 1/3 of patients with a subungal hematoma >50% will have an underlying fracture
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Subungal Hematoma
• Check for neurovascular compromise • Examine extensor tendon for signs of
tendon disruption at the DIP joint (mallet finger)
• Inspect for evidence of nail fold disruption, deformity, or avulsion (don’t want to miss a Seymor fracture)
Subungal Hematoma
• Distal Phalanx Fractures
Fracture patterns seen in the distal phalanx are (A) longitudinal, (B) transverse, (C) tuft, (D) dorsal base, (E) volar base, and (F) complete articular.
Bucholz RW, MD and Heckman JD, MD. Rockwood & Green's Fractures in Adults, 5th ed. Lippincott, Williams & Wilkins, 2001. Copyright © 2001 Lippincott Williams & Wilkins.
Ortho referral: • Loss of 2 point discrimination • Displaced or angulated transverse fractures • Intra-articular fractures
Subungal Hematoma – to remove nail or not?
Old thought: • Remove nail when the hematoma involved more than 25-50% of the nail or in
the presence of fracture because these findings have been associated with nail bed lacerations longer than 2 to 3 mm
New thought: • No need to remove nail as long as nail folds are intact!
Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999; 24 (6):1166
Subungal Hematoma - Trephination
Remind families: • Oozing of blood from the site of trephination • Nail itself does not have nerve fibers - pain caused by pressure against or
contact with the nail bed during the procedure • Discoloration of the nail lasting up to four weeks • Potential loss of the nail despite trephination related to the primary injury • Potential for clotting to plug the nail hole, leading to re-accumulation of blood • Secondary infection of the nail bed and deeper structures (rare)
Trephinate if <24-48 hours, intact nail folds, painful Clean nail with iodine (not alcohol swab) Press electrocautery on nail in center of hematoma, avoiding lanula and matrix Blood may spurt!
Cover with sterile dressing Splint if there is an underlying fracture or to protect from further injury Ortho f/u for displaced or intra-articular fractures Antibiotics not necessary, even with underlying fracture
• Prophylactic antibiotics does not appear to improve outcomes in patients with subungual hematomas and intact nail fold
Seaberg DC, Angelos WJ et al. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med, 1991; 9(3):209
Paronychia
• Acute inflammatory process, with or without abscess formation, that involves the proximal and lateral nail folds
• May spread to pulp space felon
• Skin flora: Staphylococcus aureus, Streptococcus pyogenes
• Oral flora: aerobic bacteria (such as streptococci, S. aureus, and Eikenella corrodens) and anaerobic bacteria (eg, Fusobacterium, Peptostreptococcus, Prevotella, Porphyromonas spp)
Paronychia
Felon
Paronychia
• Without abscess: warm soaks (10-15 min, several times a day) followed by topical abx ointment
• With abscess: LMX vs Freezy spray vs digital block • Soak to soften eponychium • 11 blade/large bore needle under affected cuticle margin • Incision along lateral nail fold • Warm soaks and topical abx • More severe cases consider po abx (Keflex vs Augmentin)
• No high-quality studies evaluating the use of po vs topical abx for uncomplicated paronychia or the use of po abx in addition to incision and drainage for acute paronychia with abscess
Pierrart J, Delgrande D, et al. Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surg and Rehabilitation, 2016; 35 (1) 40-43
Ring Removal
• History: • How long has it been stuck? • Material ring is made from and sentimental value?
• Preparation: • Need for pain control, i.e. digital block • Clean area with iodine • Raise hand above level of heart, ice to affected digit
to decrease swelling • Lubrication
Ring Removal
• Techniques • Ring cutter: good for thin, inexpensive rings or soft materials (gold, silver,
copper, tin, plastic) • Manual and electric versions • Clean ring cutter with alcohol • Place guard under palmar side of ring and rotate crank to turn saw blade • Use hemostats to grab the two edges and pry open the ring or make 2nd cut • Pitfalls: can get very hot; metal filings may cause infection/synovitis in pts with lacs
Ring Removal
• For hard metals such as steel or titanium:
• Wear eye protection • Wet gauze to protect from sparks • Hemostat or laryngoscope blade
under ring • Ice blade and ring before starting • Drip cold ice water during
procedure • 2 x 180 degree cuts
Ring Removal
• Manual Removal: • Double Penrose drain method:
• Apply one Penrose drain just distal to the proximal interphalangeal (PIP) joint
• Tightly wrap a second Penrose drain, starting at the first one and extending back to the incarcerated ring
• Repeat as necessary until the edema is sufficiently reduced to remove the ring
• Once the ring passes the PIP joint, remove the first Penrose drain
• BP cuff technique: • Apply BP cuff to affected extremity and inflate to SBP + 100 • Apply Penrose drain or IV tourniquet from tip of digit proximally and keep
arm elevated x 15 min • Remove Penrose drain and attempt ring removal
Ring Removal
• String pull technique: • Lubricate finger • Pass 1 end of 20 inch packing/umbilical tape under
ring until end equal length • Pull distally in a circular fashion
• String wrap technique: • Pass packing tape prox to distal under ring • Wrap beginning just distal to ring • Pull on proximal end of wrap
• Do not use these techniques in pts with lacs or fractures
Update Tetanus if needed
Hair Tourniquet
• AKA hair-thread tourniquet syndrome • Edema/ischemia of an appendage caused by a tightly wound piece of
hair or string • Part of my “fussy baby” workup
Hair Tourniquet
• If due to hair or unknown material and the skin is intact, first step is a depilatory agent
• Depilatory agents contain thioglycolates which disrupt disulfide bonds in the hair dissolution of the hair into a gelatinous form that can be wiped away
• Wipe off gauze and rinse with water after 10 minutes • 64% of hair tourniquets resolved after 1 or 2 applications of Nair
• Don’t apply near mucosal surfaces! i.e. vulva Plesa JA et al. Effect of a Depilatory Agent on Cotton, Polyester, and Rayon Versus Human Hair in a Laboratory Setting. Annals of Emerg Med, 2015; 65 (3): 256
Bean JF, Hebal F et al. A single center retrospective review of hair tourniquet syndrome and a proposed treatment algorithm. J Pediatr Surg. 2015; 50(9): 1583
Hair Tourniquet
• If able to find the loose end, unwind around digit
• If able to slip blunt probe under tourniquet, lift and then cut with scalpel or scissor
• For deep tourniquets: • Digital block • Longitudinal incision at 3 or 9 o’clock position to
avoid the neurovascular bundles
Hair Tourniquet
• Improved perfusion and pain relief is usually seen within minutes of release although swelling may persist for several days.
• Try to keep digit elevated • Prophylactic abx not necessary • Follow up in 24 hours for re-evaluation
References • Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol.
1995; 109 (12): 1219. • Backlin SA. Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med. 1995; 25 (4): 554 • Bean JF, Hebal F et al. A single center retrospective review of hair tourniquet syndrome and a proposed treatment algorithm. J Pediatr Surg.
2015; 50(9): 1583 • Brown JC, Klein EJ. The “Superhero Cape Burrito”: A Simple and Comfortable Method of Short-term Procedural Restraint. The Journal of
Emergency Medicine, Volume 41, Issue 1, 2011, 74-76. • Bucholz RW, MD and Heckman JD, MD. Rockwood & Green's Fractures in Adults, 5th ed. Lippincott, Williams & Wilkins, 2001. Copyright ©
2001 Lippincott Williams & Wilkins. • “Fish Hook Removal.” YouTube, uploaded by EM:RAP Productions, February 3, 2017. https://www.youtube.com/watch?v=nU8TprsNz44 • “Fishhook Removal Using String Method.” YouTube, uploaded by Daniel Azof, August 26, 2017.
https://www.youtube.com/watch?v=ZRgH1oLMNnI • Pierrart J, Delgrande D, et al. Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46
patients. Hand Surg and Rehabilitation, 2016; 35 (1) 40-43 • Plesa JA et al. Effect of a Depilatory Agent on Cotton, Polyester, and Rayon Versus Human Hair in a Laboratory Setting. Annals of Emerg Med,
2015; 65 (3): 256 • “Removing object from child's nose using the kiss technique.” YouTube, uploaded by Mathew Pretel, May 10, 2016,
https://www.youtube.com/watch?v=h6MSZ0HfeZA • Rollins, J. A. Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Pro-Ed, Inc, 2005. • Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999; 24
(6):1166 • Seaberg DC, Angelos WJ et al. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med, 1991;
9(3):209
Nasal Foreign Body
Nasal Foreign Body
Nasal Foreign Body
Nasal Foreign Body
Nasal Foreign Body
Nasal Foreign Body
Ear FB: EAC
Ear FB: EAC
Ear FB: EAC
Ear FB: EAC
Fish hook Removal

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Pediatric Office Based Procedures