PEM|BRS: Procedures
Central Lines:
For central venous access, acquired and congenital bleeding disorders are relative
contraindications, especially in the IJ and SC veins where hemostasis may be difficult to
obtain or may result in airway obstruction.
For femoral access, the child’s hip is abducted and externally rotated. A rolled towel can
be placed under the ipsilateral hip for improved exposure and to create a firmer surface.
Unlike in adults, use of the femoral vein is NOT associated with an increased rate of
catheter-related infections compared to other central venous sites.
SC Vein is the least common site used for percutaneous central venous cannulation in
children due to the increased compliance of their chest wall and the small size of the
chest and clavicle, which makes landmark ID more difficult. In addition, there is a high
incidence of PTX and subclavian artery injury.
The femoral vein is easily identifiable anatomically and does not interfere with airway
management or chest compressions during resuscitation. The femoral vein can be
identified 1-2 cm medial to the femoral artery pulse in the femoral triangle inferior to the
inguinal ligament. When there is a weak or absent pulse, the femoral vein can be assumed
to be located halfway between the pubic tubercle and the anterior iliac spine. The
patient’s hip should be abducted and externally rotated. The needle is inserted 1-2 cm
below the inguinal ligament at a 45 degree angle. The needle is advanced in the direction
of the ischial tuberosity but should NEVER pass beyond the inguinal ligament, as this
can result in bowel perforation or accumulation of a retroperitoneal hematoma.
Regardless of the site, the basic steps in the Seldinger technique are to:
Administer local anesthetic, prepare the site, and create a sterile field.
Flush the catheters.
Identify landmarks.
Puncture the vein with the needle attached to syringe.
Detach the syringe.
Thread the J-wire through the needle and into the vessel. If premature ventricular
contractions are triggered, the wire has advanced too far. Occasionally, more
sustained arrhythmias can result when the ventricle is “tickled” by the wire tip.
Be prepared with a defibrillator.
Withdraw the needle over the wire while AT ALL TIMES maintaining control of the
tip of the wire. Discard the needle.
Make a small incision with a scalpel at the skin without cutting the wire.
Dilate the soft tissue with dilator over the wire, again always maintaining control of the
exposed wire.
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Withdraw the dilator and thread the catheter over the wire to the desired depth, again
maintaining control of the wire.
Withdraw the wire and keep pressure on the catheter to prevent air embolus.
Draw back and flush all ports to ascertain that all ports are intravascular.
Transduce the pressure at the distal port to ascertain venous placement.
For IJ and SC lines, obtain a chest radiograph to confirm that the catheter tip is outside
of the right atrium and to look for pneumothorax.
Secure the catheter to the skin, usually with silk sutures. Do not forget to use local
anesthetic if the area was not anesthetized previously.
Place a sterile dressing.
The IJV and SV are more easily approached from the right side of the patient. On the
right, the IJV follows a straight course and joins the right SV while the left IJV joins the
SV at a more acute angle—in addition, the left thoracic duct enters the left SV at its
junction with the IJV, which can hinder venous cannulation. Also, the higher left pleural
dome increases the likelihood of a PTX.
The IJ vein offers the most direct route to the superior vena cava (SVC). The course of
the IJ is within the carotid sheath and, therefore, in close proximity to the carotid artery
and the vagus nerve.
Landmarks include the triangle formed by the two heads of the sternocleidomastoid
muscle and the clavicle. Obviously, care should be taken to avoid puncturing the carotid
artery, which lies medial to the IJ. The nondominant hand should be used for
identification of the carotid artery. The needle should be directed toward the
IPSILATERAL nipple.
Cut down procedures are generally implemented for saphenous vein cannulation, and is
usually an option if femoral vein catheterization has failed.
Topical Anesthesia:
TAC (tetracaine, adrenaline, and cocaine) is primarly used for lacs on the face and scalp.
TAC and LET (Lidocaine, Epinephrine, Tetracaine) are contraindicated in areas of endarteriorlar supply (pinna, nasal alae, penis, and digits). Blanching of surrounding skin
indicates onset of anesthesia. Contact with eyes can cause corneal injury. TAC and LET
should not be used on mucous membranes or areas of extensive burns or abrasions as
excessive uptake into the systemic circulation can cause toxicity. Should be used
cautiously in patients with seizures as excessive amounts can cause agitation,
tachycardia, seizures, and apnea. Absorption of the cocaine and lidocaine may
exacerbate seizures and cardiac arrhythmias.
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Umbilical Lines:
The UA can be accessed within the first 24 hours of life and occasionally up to 7 days.
The UV can be accessed up to 2 weeks of life. Both the UA and UV can be used for
administration of medication or fluids. The umbilical cord should be cut transversely
0.5-2cm from the base to identify the vessels. The catheter should be passed cephalad for
4-5cm or until blood return is noted. Lower extremity ischemia can be caused by
vasospasm of the UA and can be relieve with warm compresses applied to the contralateral extremity triggering a reflex vasodilation in the affected extremity.
Umbilical cannulation must not be attempted in neonates with an omphalocele,
omphalitis, suspicion of NEC, or peritonitis.
For a high UA line, the estimated insertion depth is 1cm + distance from should to
umbilical stump.
For a low UV line, advance 1 cm beyond distance where blood return first occurs. For a
high UV line, the insertion depth is 2/3 of the shoulder to umbilicus distance.
The UA connects with the internal iliac artery then the abdominal aorta (so on x-ray, it
goes caudally before cephalad). The UV joins with portal vein and the inferior vena
cava.
The correct position of the UVC is just above the diaphragm or, in acute resuscitations,
just proximal to the umbilical stump. Umbilical vessel catheterization is a sterile
procedure, and the initial steps are the same for both umbilical artery and vein.
Differences in the steps for catheterizing the umbilical artery and vein include the
technique for dilating each vessel, catheter advancement, some potential pitfalls, and
determination of the proper placement. An umbilical artery is technically more difficult
to cannulate because it is smaller, thicker-walled, and usually vasoconstricted compared
to the umbilical vein. The umbilical vein needs to be cannulated only to the minimum
distance that establishes adequate blood return (usually approximately 2 to 4 cm past the
skin) in the setting of cardiopulmonary arrest.
The UAC catheter tip lies at the level of the 3rd and 4th lumbar vertebrae for the low
position. The catheter tip is above the diaphragm at the level between the 6th and 9th
thoracic vertebrae for the high position. A 2000 Cochrane Review suggested that the high
position is the preferred placement because it is associated with fewer clinical vascular
complications and longer duration of service.
UAC distance (cm) = 3 x birthweight (kg) + 9
UVC distance (cm) = [3 x birthweight (kg) + 9]/2 + 1
The tip of the UVC should be in the inferior vena cava, above the level of the ductus
venosus and hepatic veins (above the diaphragm), below the level of the right atrium,
with the catheter tip between T8-T9.
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Lumbar Puncture:
The lateral recumbent position and the sitting position can be used in all age groups while
performing an LP. The puncture site is identified by lining up the upper aspects of the
superior posterior iliac crests and finding the L3-L4 or L4-L5 interspace. The needle
should be directed parallel to the bed but slightly cephalad (toward the umbilicus) in the
lateral recumbent position. Topical anesthetic, subcu 1% lido, and “sucrose dipped
pacifiers” have all shown efficacy in reducing pain during this procedure.
Foreign Body in Airway:
For a choking patient under 1 year of age, you deliver 5 back blows between the shoulder
blades followed by 5 chest thrusts on the sternum. Abdominal thrusts (Heimlich
maneuver) are indicated in older patients and are performed with the patient sitting or
standing if conscious, or lying down if the patient is unconscious. A blind finger sweep
is not recommended in the ED, but rather direct visualization of the airway by direct
laryngoscopy and removal of the FB with Magill forceps.
Foreign Bodies in Ear:
Irrigation should never be used with vegetable matter that can expand, with button
batteries, or if there is a possibility of TM perforation.
In most cases, allowing FB’s to stay in the external auditory canal while the patient waits
for referral is safe. Exceptions include if the FB is associated with infection and presence
of a button/disk battery.
IO Access:
The entry site is half-way between the anterior and posterior border of the tibia, 1-2cm
distal to the tibial plateau. The needle should be perpendicular to the bone and angled
slightly away from the joint space. Gradual pressure with a rotational motion is applied
until you feel a sudden decrease in resistance. The most common sites used are the
proximal tibia, the distal tibia, and then the distal femur. The proximal tibia is used in
patients until 4 years of age. After that age, the proximal tibia is more difficult to
penetrate manually, and therefore the distal tibia or femur should be used. With the
newer auto-injection devices, access can be obtained in patients of all ages at all sites.
IO lines can be used in children of any age.
IO lines should not be placed in children with osteogenesis imperfecta or osteoporosis,
and bones that are fractured or infected should not be used. An overlying burn or
cellulitis is a relative contraindication.
In infants < 2 mo of age, the distal femur is the preferred IO site because the proximal
tibia is often too thin. For the distal femur site, the IO catheter is inserted midline, 2-3cm
above the femoral epicondyles.
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The proximal tibia is an excellent site until about 4 years of age when the cortex becomes
more difficult to penetrate. The site is medial and 1-2cm distal to the tibial tuberosity, on
the flat part of the tibia.
The distal tibial site is entered 1 cm superior to the medial malleolus, on the flat part of
the tibia.
Confirmation of IO placement includes:
1) Needle that stands firmly without moving
2) Aspiration of bone marrow (only possible about 50% of time—aspirated marrow
can be sent for all blood tests except a CBC)
3) Easy flushing with saline
Complications of IO lines include:
1) Not penetrating cortex or going into and through the other side. Large volumes of
infused fluid could cause compartment syndrome.
2) Osteomyelitis
3) Cellulits (both 2 & 3) are directly related to duration of use, therefore, discontinue
promptly when more definitive access obtained.
4) Fat embolism
5) Growth plate injury
Dislocations:
Dislocations of Digits: The longer arm of the PIP joint accounts for higher frequency of
dislocations when compared to the DIP joint. Although digit dislocations are evident on
physical exam, appropriate x-rays should be obtained before and after reduction to
evaluate the nature of the dislocation, the alignment of the digiti and presence of any
associated fractures. Digital block anesthesia should be performed before the reduction.
For the purpose of closed reduction, the joint should be hyperextended while gentle
longitudinal traction is applied for a dorsal dislocation. The joint should be immobilized
with a splint for 1-2 weeks.
An anterior shoulder dislocation is the most common joint dislocation in adolescents. In
reduction by gravity, while the patient is in the prone position, the dislocated shoulder
should be placed in forward flexion and slight external rotation and 5 kg weights applied
to wrists for downward traction. During scapular manipulation, the superior aspect of the
scapula should be pushed laterally and the scapular tip medially when downward traction
by weight is applied to the affected extremity. You can also use the external rotation
technique with the elbow flexed and using longitudinal traction on the humerus.
TMJ is often displaced anteriorly; before attempting reduction, radiographs should be
considered if there is any suspicion of fracture. A local intra-articular or IM
administration of lido may help with the reduction by relaxing the lateral pterygoid and
temporalis muscles. Manual reduction is done by placing the thumb against the lower
posterior molars and wrapping the fingers around the angle and body of the mandible
while applying slow steady pressure first downward and then posteriorly. The person
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performing the procedure should wrap their thumbs in gauze or a splint to protect
themselves from being bitten. Dislocation associated with fracture should be referred to
an oral surgeon and the ED physician should not attempt a reduction of the dislocation.
Hypothermia:
Mild hypothermia: core body temp 34-35 C
Moderate hypothermia: core body temp 30-34 C
Severe hypothermia: core body temp < 30 C
Passive rewarming techniques are indicated for rectal temperatures at or above 30 C and
include the following: removing wet clothing, warming the room, using warm or
insulating blankets.
Active rewarming is indicated for rectal temperatures < 30 C (severe hypothermia) and
may include bladder, gastric, peritoneal, and/or thoracic lavage using saline warmed to
40-41 C. In patients with cardiac arrest or dysrhythmias not responsive to conventional
management, cardiac bypass may be necessary.
Hypothermic patients should have their core body temperature monitored with a rectal
probe. When the core temp falls below 30 C, the incidence of cardiac arrhythmias
increases and at 28 C ventricular fibrillation may result. J waves (elevation of the J
point—also called Osborn Waves) on the ECG may be seen in moderate or severe
hypothermia—their presence increases the likelihood of VF.
Oral/Nasal Airways:
Oropharyngeal airways are used in unconscious patients. The tip of the oropharyngeal
airway should reach the angle of the mandible when the flange is at the central incisors.
NP airway choice: the tip should reach the lobule of the ear when the opposite end
touches the ipsilateral naris.
Facemasks should be the smallest size that completely covers the nose and mouth. The
ventilator rate of the child should be 16-20 breaths/min.
Peripheral Vascular Access:
Vascular access should NOT delay or interfere with airway management in a critically ill
child.
Venous access should be avoided in areas distal to an injury. Areas of edema, overlying
burns, or cellulitis should also be avoided.
May try an EJ when other sites have been unsuccessful. EJ passes posteriorly over the
SCM from the angle of the jaw. Place patient in trendelenburg with lateral neck rotation
(positioning contraindicated in suspected neck injury)
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Enterostomy Tube Replacement:
Contraindications to replacing enterostomy tubes include recently placed tubes with an
immature fistula tract (within 8 weeks of initial operative procedure), or the presence of
peritoneal signs.
May use hegar dilators or foley catheters to dilate site.
Tracheostomy Tube Replacement:
Respiratory distress in a patient with a tracheostomy indicates tube obstruction until
proven otherwise.
It is important to ascertain and understand the indication for patient’s tracheostomy.
Can use ETCO2 colorimetric or capnographic devices to check placement. Do not fall
into the mistake of assuming a tube in the stoma means the tube is in place—check for
placement using exam and noninvasive monitoring techniques.
Clearing a potentially obstructed tube: instill 1-2 cc of NS, and insert the largest suction
catheter that will fit—once patient starts coughing, it is in deep enough, suction for 5
seconds (not more than 10) at 100 mm Hg. Stop if bradycardia or cyanosis develops. If
suction unavailable, may try replacing the obturator into position or a smaller tube into
the trach tube to dislodge the obstruction. If the obstruction still cannot be cleared, the
tube must be exchanged.
Ventilator Management:
The problem with pressure-controlled ventilation is that a change in lung compliance will
result in a change in tidal volume. Agitation or secretions may dramatically decrease the
delivered gas volume. The advantage is that the risk of barotrauma and pneumothorax is
reduced.
The problem with volume-controlled ventilation is that the risk of pneumothorax and
barotraumas is higher. The advantage is that tidal volume is preserved, regardless of
changes in patient’s lung compliance. The first manifestation of a pneumothorax in this
mode may be a rise in the pressure observed during the inspiration of a tidal volume.
You can combine these modes using PRVC (pressure-regulated/volume controlled
ventilation). Here, gas is delivered to the airway until a maximum pressure is achieved,
and inspiration is continued until a predetermined tidal volume is delivered.
In the ventilation of a lung with near-normal compliance and diffusion characteristics, the
I:E ratio is 0.5. In a poorly compliant lung with impaired diffusion, the I:E ratio may be
prolonged to 2-3 (termed, “inverted”). This is not without its consequences—when you
increase length of inspiration, you decrease length of expiration. The resulting increase
in MAP may decrease cardiac output. Shortened expiration may lead to gas trapping.
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In status asthmaticus, you use permissive hypercapnea (keep arterial pH > 7.2 and pCO2
60-70) in order avoid large pressures and short E times which would otherwise increase
PTX risk. Use this also for congenital diaphragmatic hernia.
Initial ventilator settings:
 TV: 10 cc/kg (infant and toddler); 8cc/kg (child); 7 cc/kg (adolescent)
 Rate: 20 bpm (infant and toddler); 12 child; 10 adolescent
 Peak pressure: 25-30 cm H2O
 PEEP: 5 cm H2O
 Pressure support: 10 cm H2O
 I time: 0.8 sec (infant), 0.9 sec (toddler); 1 sec (child and adolescent)
Pneumo/Hemothorax:
Aggressive fluid resuscitation and administration of blood products are important for
patients with massive hemothorax BEFORE significant evacuation is begun. An initial
amount of blood drainage of 15cc/kg or subsequent drainage of 4cc/kg/hr x 4 hr is an
indication for an open thoracotomy.
An open PTX is managed FIRST with occlusion of the chest wall defect with a 3-sided
dressing, followed rapidly by tube thoracostomy at an alternate site.
The sole presentation of a tension PTX in a child may be respiratory distress followed by
overt signs of shock.
Hernia Reduction:
Contraindication to manual reduction of inguinal hernia: child extremely ill with signs of
toxicity from gangrenous bowel or peritoneal irritation.
In a female, if an incarcerated inguinal hernia will not reduce, an incarcerated ovary is
likely.
Subungual Hematoma:
A subungual hematoma > 30% warrants evacuation.
Felon Management:
For felons, use the volar longitudinal incision—start 5mm distal to the DIP joint and
extend to end of the phalanx—cut down only to the dermis, explore, irrigate, drain, pack,
dress, splint.
Pacemakers:
Placement of a magnet over the pulse generator of a pacemaker turns off all programmed
functions and forces the pacemaker to pace at a fixed rate regardless of the heart’s
activity.
Any symptomatic patient with a pacemaker dysfunction requires transcutaneous pacing.
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If cardioversion or defibrillation is required in a patient with a pacemaker or defibrillator,
the paddles are placed as far from the pulse generator as possible.
Splints:
 Sugar-Tong: fractures of the wrist and distal forearm
 Volar: Buckle fractures or sprains
 Thumb-Spica: scaphoid, 1st metacarpal, or first proximal phalynx
 Long arm: Elbow or proximal forearm
 Ulnar Gutter: 4th & 5th metacarpals (slight flexioin at IP joints, 90 flexion at MCP
& slight extension at the wrist)
 Radial Gutter: 2nd & 3rd metacarpal
 Finger splints: apply from MCP joint around to dorsum of wrist and maintain IP
joint flexion
Presentation of Cardiac Tamponade:
Signs of cardiac tamponade include: tachycardia, hypotension, tachypnea, narrow pulse
pressure, and pulsus paradoxus. The combination of Beck’s Triad (muffled heart tones,
JVD, and hypotension) is uncommonly seen.
Suturing:
The half-buried horizontal mattress stitch, also referred to as a corner stitch, is the
preferred stitch for closing a wound flap. Because this stitch passes through the dermis of
the flap, it creates less tension and, therefore, preserves the distal flap that may consist
only of a thin layer of epidermis with poor vascular supply. The remainder of the wound
should be closed with horizontal mattress stitches that help eliminate tension on large or
gaping wounds.
The basic principles of wound repair are to restore anatomy, avoid
infection, and achieve hemostasis.
A running suture is used for rapid percutaneous closure of long, uncomplicated wounds
that align easily and are at a low risk for infection. This technique provides even tension
along the length of the wound and easy suture removal. The first step is to place a single
interrupted stitch at the edge of the wound, followed, without cutting the suture after the
first knot is tied, with the placement of repeated running sutures at 45-degree angle bites
along the entire wound. The loop of the final bite is kept loose and is used as a free end to
tie the knot.
Subcuticular running sutures generally are placed to close linear lacerations on the face
and reduce scarring. Using absorbable sutures, a single anchoring stitch is placed at one
end of the wound, followed by multiple sequential mirror-image bites at the same
subcutaneous plane taken horizontally for the full length of the laceration.
Both vertical and horizontal mattress sutures can be used to reduce wound tension and
achieve eversion of wound edges, but these types of sutures are associated with a higher
risk of ischemia of the wound edges. A vertical mattress suture is placed by taking a bite
at a distance from the wound edge, crossing through the dermal tissue, and exiting
through the skin at the opposite side at an equal distance. This is considered the far-far
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portion of the suture. This is followed by turning the needle 180 degrees to reverse the
direction of the suture loop and taking a smaller bite closer to the wound edge on the
same side. The needle is brought out at the side of the original stitch, and the knot is tied
to approximate the wound edges. This is considered the near-near portion. Both points of
needle entry and exit are in the same straight line.
The horizontal mattress suture is
started by placing a stitch in the usual manner and bringing it out at the opposite side. The
second bite is taken 0.5 cm from the first exit site and brought back to the original
starting site at the same distance for the knot to be tied.
The v-shaped laceration with
the flap is closed by using a half-buried horizontal mattress suture, where the needle is
introduced through the skin of the nonflap portion and passed horizontally through the
dermal portion of the flap (buried), with the suture loop completed by bringing the needle
out through the skin on the opposite side of the nonflap portion of the wound. In some
instances, it is advisable to extend the v-shaped laceration to a V-Y laceration to reduce
tension at the flap. There is no such thing as a half-buried vertical mattress suture.
Orofacial Nerve Blocks:
V1/Opthalmic Division
Supplies: Forehead, upper eyelid, nasal bridge and tip
Point of exit from skull: Supraorbital foramen
Landmarks for block (supraorbital): Inject 0.5 to 1 cm depth medial to supraorbital notch
V2/Maxillary Division
Supplies: Lower eyelid, upper lip, anterior maxillary teeth
Point of exit from skull: Infraorbital foramen
Landmarks for block (infraorbital): Insert needle anterior to first maxillary premolar
while marking infraorbital foramen (0.5 cm below infraorbital notch) with finger; inject
at depth of 1 to 2 cm
V3/Mandibular Division
Supplies: Mandible, lower lip, chin, mandibular teeth
Point of exit from skull: Mandibular foramen
Landmarks for block (inferior alveolar): Grasp mandible between index finger and thumb
of nondominant hand, marking coronoid notch with the intraoral digit; hold syringe along
occlusal plane of the mandible, aiming slightly superior in adolescents and adults and
slightly inferior in younger children; inject at depth of 1 to 1.5 cm
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Mental Nerve
Supplies: Lower lip and chin
Point of exit from skull: Mental foramen
Landmarks for block (mental): Insert needle over mandible along a line that crosses the
supraorbital and infraorbital foramen and the premolars (palpate mental foramen); inject
at a depth of 0.5 cm
A line can be drawn from the supraorbital notch, through the pupil of the eye, through the
infraorbital notch and foramen, across the maxillary and mandibular premolars, and
through the mental foramen. In this way, all three branches of the trigeminal nerve can be
easily located.
For an infraorbital block, the index finger of the nondominant hand is used to palpate a
depression about 0.5 cm below the infraorbital notch, which marks the site of the
infraorbital foramen. The thumb or fingers of the same hand are used to retract the upper
lip. The dominant hand is used to insert the needle into the mucolabial fold just anterior
to the apex of the first premolar tooth. The needle should be advanced no more than 1 to
2 cm from the insertion point toward the infraorbital foramen and along the axis of the
tooth. The tip of the index finger helps to guide the needle and prevent advancement of
the needle to the orbital cavity. Once the tip of the needle is positioned above the
infraorbital foramen, 1 to 2 mL of anesthetic is injected.
An alternative approach involves injecting the anesthetic through the skin directly into
the infraorbital foramen. However, caution must be exercised with this approach because
the nerve may be damaged if the needle is advanced into the foramen itself.
Injection of local anesthetic at a depth of 1 to 1.5 cm into the coronoid notch of the
mandible along the occlusal plane produces an alveolar nerve block; the needle should be
directed slightly superior to the occlusal plane in adolescents and adults and slightly
inferior to the occlusal plane in younger children. The alveolar nerve is the largest branch
of the mandibular division, or V3, of the trigeminal nerve and provides innervation to the
mandibular teeth, lower lip, and chin on the involved side.
Local anesthetic administration medial to the supraorbital notch provides a supraorbital
block, with anesthesia of the ipsilateral forehead. Injection of local anesthetic into the
mental foramen provides anesthesia to the lower lip and chin on the ipsilateral side.
Supraperiosteal infiltration provides anesthesia to a single tooth. A buccal approach is
used to advance the needle 1.5 cm into the mucolabial fold of the corresponding tooth.
One to two milliliters of anesthetic is infiltrated along the periosteum at the apex of the
root. Due to the porosity of the maxilla, supraperiosteal infiltration is effective for the
maxillary teeth throughout life. However, because the mandible is significantly denser
and less porous in adults, this form of anesthesia useful only for maxillary teeth in older
adolescents and adults.
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Orofacial anesthesia involves local or regional infiltration of an anesthetic agent to
provide pain relief or to prevent pain associated with repair of facial injuries or
infections. The decision to use local infiltration or a regional block is based on the
location and type of injury or infection, concern regarding distortion of landmarks with
local infiltration, damage to or distortion of normal block landmarks by injury or
infection, and level of cooperation of the patient. An absolute contraindication to
orofacial anesthesia is a documented allergy to local anesthetic agents. Injection of
anesthesia into or through infected or grossly contaminated tissues is relatively
contraindicated.
Small, clean wounds are usually amenable to local infiltration. Regional nerve blocks
generally require the use of less anesthetic, usually only 1 to 2 mL for orofacial blocks,
reducing the risk of toxicity or adverse reactions. Significant wounds to cosmetically
important areas, such as lacerations through the vermilion border, may be better served
with regional anesthesia to avoid distortion of key landmarks. Multiple wounds in the
same nerve distribution may be repaired with fewer injections, less time, less anesthetic,
and less discomfort using a single regional block.
Preparatory steps can increase the likelihood of success of orofacial nerve blocks.
Depending on the patient’s age, degree of anxiety, and level of cooperation, consideration
should be given to the use of distraction, restraints, medical anxiolysis, or procedural
sedation before beginning the procedure. For those blocks administered via the intraoral
route (supraperiosteal infiltration, infraorbital, inferior alveolar), the application of topical
mucosal anesthesia before performing the block can reduce or eliminate the pain of
needle insertion. The area initially is dried with a gauze pad, followed by application of
topical mucosal anesthetic (20% benzocaine or 5% to 10% lidocaine) to the insertion site.
Local anesthesia should be achieved within 30 to 90 seconds.
A 27-gauge needle generally is recommended for injection in orofacial blocks; the use of
larger-bore needles increases the pain associated with the procedure. Use of warmed and
buffered anesthetic solutions can further minimize the patient’s discomfort. Following
infiltration of 1 to 2 mL of anesthetic, at least 5 minutes is required to achieve regional
anesthesia. Failure to achieve anesthesia can result from improper technique, anatomic
variation, insufficient anesthetic volume, or inadequate time before performing the
procedure. Other complications of orofacial anesthesia include intravascular injection of
anesthetic, improper needle position causing injury to adjacent structures, and allergic
reaction to the anesthetic.
Suprapubic Bladder Aspiration:
Collection of a urine specimen is indicated for a febrile infant younger than 2 months of
age as part of evaluation for possible sepsis. Suprapubic bladder aspiration (SPA) or
transurethral bladder catheterization (TUC) are the two standard methods used. The
simplest and most efficient of these methods is TUC, but if this is not possible due to
anatomic or technical difficulties, SPA should be considered. Before undertaking this
approach, it is prudent to maximize the likelihood of success by ensuring that urine is
present in the bladder. Administration of an intravenous bolus of normal saline before an
attempted SPA is an appropriate course of action. Antibiotics can then be administered
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after collection of the urine sample. Repeated attempts at TUC in the presence of labial
adhesions, use of urine from the diaper, and manual lysis of the adhesions are
inappropriate. A urine bag may be considered if SPA is beyond the technical abilities of
the clinician.
SPA has been in use since the early 1950s. If urine is obtained, the sensitivity for
detection of urinary tract infection by this procedure approaches nearly 100%, making it
the diagnostic gold standard. Due to the invasiveness, pain, and greater failure rate for
SPA compared to TUC (successful attempts range from 23% to 90%), TUC has become
the method of choice for children younger than 2 years of age. Although studies have
found that TUC is less painful, the approach through a relatively nonsterile urethra does
introduce a greater likelihood of bacterial contamination of the urine specimen.
Beyond 2 years of age or after the child is toilet trained, the clean-catch technique is used
for urine collection because of its relative ease and noninvasiveness. Specimens collected
by urine bag can be used to screen for urinary tract infection in children between 2
months and 2 years of age when they are not sick enough to require immediate
antibiotics. If the specimen is positive (presence of leukocyte esterase or nitrite, bacteria
evident on microscopic examination of a Gram stain specimen, or detection of more than
5 white blood cells on a noncentrifuged urine specimen), then repeat urine specimen
collection is indicated via TUC or SPA to confirm the infection. Antibiotics for presumed
urinary tract infection should not be started on the basis of findings from specimens
collected by urine bag alone.
Indications for SPA are: difficulty in accessing the urethra in children younger than 2
years of age due to labial adhesions, foreskin adhesions, or any other technical problem
that prevents collection of urine by TUC. Fecal incontinence in a child who has
gastroenteritis is a relative indication. Contraindications include some genitourinary tract
abnormalities, infection of the abdominal wall at the collection site, bleeding diathesis,
and neutropenia. Studies have shown that pain associated with SPA can be reduced with
the use of topical anesthetics and that the success of SPA is related to the patient’s
hydration status. SPA success rates have increased when the procedure is used in
conjunction withultrasonography. Ultrasonography allows for determination of bladder
volume and guidance for aspiration by showing where the bladder is closest to the
abdominal wall. The minimum recommended bladder measurements for successful
collection of urine are 2 cm or more in transverse and anteroposterior diameters or at
least 10 mL of measured bladder urine volume.
Under sterile conditions, the patient’s abdominal wall is prepped with appropriate
antiseptic and the patient is held in the frogleg position. Local anesthesia with injection or
cream is recommended to reduce pain. The bladder is percussed to determine if it is full
before attempting SPA. The entry point is 1 to 2 cm above the symphysis-pubis in the
midline. Use of a 22-gauge 1.5-inch needle attached to a 3- to 5-mL syringe is
recommended. The direction of insertion is 10 to 20 degrees from perpendicular, angled
toward the umbilicus. The plunger on the syringe is pulled back after the skin is pierced
to create negative pressure until urine returns. If this is not successful, the needle can be
directed more perpendicularly without removing it. If this attempt is also unsuccessful,
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the patient should be hydrated and the attempt may be repeated in 30 to 60 minutes.
Complications of SPA are rare and include intestinal penetration, infection of the
abdominal wall, and transient hematuria. These can be avoided by proper identification of
landmarks and use of sterile technique. Rare cases have been reported of bladder wall
thickening after SPA in patients who have bleeding diatheses. Development of abdominal
wall abscess has been reported in neonates who have fever and transient neutropenia.
There is no evidence of bacteremia after SPA in patients who have documented urinary
tract infection. When ultrasonographic guidance is used, care must be taken to avoid
applying excessive pressure with the probe onto the bladder to prevent early micturition,
which can be prevented by manual pressure on the urethral meatus.
Tissue Adhesives:
Tissue adhesives are an alternative to suturing for low-tension wounds that are linear and
less than 4 cm in length, do not abut mucosal surfaces, and are not grossly contaminated.
Multiple studies have shown equivalent rates of wound dehiscence and infection in
wounds closed with tissue adhesive compared with suture closure if the wounds are
appropriately chosen. Tissue adhesives should not be used on wounds that cross joints
(because they are considered high tension) or on the hands (because frequent washing can
prematurely break down the tissue adhesive). Similar cosmetic outcomes are achieved
with tissue adhesive and suture closure. Because no sutures or staples need to be
removed, no follow-up visit is required. As always, parents should be instructed return
with the child if there are signs or symptoms of infection.
Wound cleansing and debridement are the most important steps to prevent secondary
infection. For the boy described in the vignette, the wound can be cleaned after
administration of a topical anesthetic such as LET (lidocaine, epinephrine, and
tetracaine). Irrigation into an open wound without local anesthesia is painful and likely
would make the toddler uncooperative for further care, including application of the tissue
adhesive. The wound needs to be dry and well approximated for appropriate application
of tissue adhesive. Cyanoacrylate tissue adhesive bonds the epithelial layer of skin when
the monomer chemically changes to a polymer in the presence of moisture of the skin
surface. This exothermic reaction, resulting in heat generation (that may be felt by the
child), is exacerbated by the presence of blood or irrigation fluid. If the wound is not well
approximated, tissue adhesive enters it and keeps the edges apart. Some practitioners
recommend approximating the wound with tape strips before applying tissue adhesive,
rather than approximating it manually, which decreases the chance of gluing the holder to
the patient. When the wound is in the facial area, the clinician should take care to
prevent tissue adhesive from dripping into the eyes by positioning the patient so the
adhesive rolls away from the eye. Alternately, the clinician can place a barrier of
petrolatum or antibiotic ointment between the eye and the laceration. Tissue adhesive
may be removed with a petrolatum-based product if it inadvertently enters the wound or
adheres to an unintended surface.
A systematic analysis indicated that use of tissue adhesive is less time-intensive than
suturing, with a labor time of 8.6 minutes for sutures and 4.0 minutes for tissue
adhesives.
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