Pediatric Office Based Procedures

Pediatric Office Based Procedures Ellen Szydlowski, MD Pediatric Office Based Procedures Ellen Szydlowski, MD Assistant Professor of Pediatrics Director of Procedural Education Division of Emergency Medicine Children’s Hospital of Philadelphia

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

• Upon completion, participants will be able to

• 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

• Pediatric considerations • Foreign body removal • Nose • Ear • Earring • Fish hook removal • Finger procedures • Subungal hematoma • Paronychia • Ring removal • Hair tourniquet Pediatric Considerations

• General considerations: • Parental anxiety exacerbates the situation • One Voice • Developmental stage of child • Pain management • 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 Pediatric Considerations

• 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. Pediatric Considerations

• 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 Pediatric Considerations

• 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 Pediatric Considerations

• 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 Nasal Foreign Body

• Smooth, round solid objects (beads, Legos) :

Katz extractor

8-10 French Foley 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 Ear FB: 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

• Supplies: • LMX • Lidocaine • 11 blade scalpel • 2 hemostats 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 – String Technique Fish hook Removal

• Irrigate wound after removal and prescribe antibiotic ointment. • Consider systemic antibiotics if near a joint or patient is immunocompromised. • Review Tetanus vaccination with family. Finger Procedures

• Subungal hematomas

• Paronychias

• Ring removal

• Hair tourniquet Subungal Hematoma

• 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

• 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.

Ortho referral: • Loss of 2 point discrimination • Displaced or angulated transverse fractures • Intra-articular fractures

Bucholz RW, MD and Heckman JD, MD. Rockwood & Green's Fractures in Adults, 5th ed. Lippincott, Williams & Wilkins, 2001. Copyright © 2001 Lippincott Williams & Wilkins. 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) Subungal Hematoma - Trephination

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! Subungal Hematoma - Trephination

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

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 Felon • Oral flora: aerobic bacteria (such as streptococci, S. aureus, and Eikenella corrodens) and anaerobic bacteria (eg, Fusobacterium, Peptostreptococcus, Prevotella, Porphyromonas spp) 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 Pierrart J, Delgrande D, et al. Acute felon addition to incision and drainage for acute paronychia with and paronychia: Antibiotics not necessary abscess 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

• Mechanical removal for superficial tourniquets: • 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