Comfort in pediatric minor proceduresPain free laceration repair for Esteban and Elsa

EVELYNE D. TROTTIER, MD FRCPC PEDIATRIC EMERGENCY, CHU STE JUSTINEREVIEW BY: DR JOCELYN GRAVEL, MD, MSC, FRCPC, CHU STE JUSTINE, QCDR MATTHIEU VINCENT, MD FRCPC, HÔPITAL CHARLES-LEMOYNE, QCDR SIM GREWAL, MD FRCPC, BC CHILDREN’S HOSPITAL, BCDR SAMINA ALI, MD FRCPC, STOLLERY CHILDREN’S HOSPITAL, AB

NO CONFLICT March 2016

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Objectives

Laceration repair in the ED Importance of non pharmacologic intervention Importance of topical anesthetics Effectiveness of tissue adhesives Indication for absorbable sutures Indication for procedural sedation and analgesia

Case 1: Esteban, 2 yo, meets the coffee table corner…

www.mja.com.au

Esteban’s facial laceration: Evaluation

Exclude other injuries Exclude foreign body Confirm adequate immunization Baseline interventions: ‘‘The Essentials’’

Distraction + Positioning Topical anesthetics Glue/skin adhesives Generally, no sedation for simple laceration

Young MJA 2005www.rch.org.au/clinicalguide: Lacerationswww.childrensmn.org/services/care-specialities-deparments/pain-program/childrens-comfort-promise/

Tetanus prophylaxis

www.urgencehsj.ca/referentiels/plaies-prophylaxie-antitetanique-2-mois-6-ans/www.urgencehsj.ca/referentiels/plaies-prophylaxie-antitetanique-7-ans-et-plus/

Fein Pediatrics 2012Sinha Pediatrics 2006Young MJA 2005Ha Int J Nurs Pract 2013

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Gain their trust!

Esteban’s Laceration: The Essentials

Keep child in contact with his/her parent Be flexible and creative

Preparation: Explain in a manner appropriate for the child’s age Be at their eye level Do not lie: ‘‘It’s not going to hurt…’’ Avoid the term ‘‘pain’’

Use distraction Childlife specialist, if available

Esteban’s facial laceration: Topical Anesthetics-LET gel

LET Gel: Lidocaine 4% Epinephrine 0.1% Tetracaine 0.5% From triage (AAP recommendation)

Application: 30 min in wound

LET Gel superior to LET liquid

Dose AAP 3mL if >17kg, 0.175 mL/kg if < 17 kg

Sherman PEC 2014Harman CMAJ 2013Fein Pediatrics 2012Nicks IJEM 2010Godin Md Qc 2006www.rch.org.au: lacerationwww.urgencehsj.ca

Indications:Laceration < 5cm Laceration will require sutures Reduces discomfort while cleaning the wound Helps to achieve wound hemostasis prior to glue

Sherman PEC 2014Harman CMAJ 2013Fein Pediatrics 2012Nicks IJEM 2010Godin Md Qc 2006www.urgencehsj.ca

Esteban’s facial laceration: Topical Anesthetics-LET gel

Contraindications: ≤ 3 months Allergy Laceration is on a mucosal surface Large wound Contaminated wound Precaution on extremities such as nose or ears High BP, peripheral vascular disease Sherman PEC 2014

Harman CMAJ 2013Fein Pediatrics 2012Nicks IJEM 2010Godin Md Qc 2006White PEC 2004www.urgencehsj.ca

Esteban’s facial laceration: Topical Anesthetics-LET gel

Glue (-cyanoacrylate) Excellent esthetic outcome Similar to sutures

Farion Cochrane 2009 (Review of 2002)Singer AJEM 2008Beam, JAT 2008Godin Md Qc 2006Young MJA 2005www.rch.org.au/clinicalguide

Esteban’s facial laceration:Glue/tissue adhesives

Butylcyanoacrylate Octylcyanoacrylate

Esteban’s facial laceration:Glue/tissue adhesives

Small increased rate of dehiscence ↑ strength with steristrips and benjoin

For patients: Less discomfort, no removal needed

For Clinician: Easy to use, faster, no needle Apply on dried wound edges brought together Avoid glue in the wound= act as a foreign body

Singer AJEM 2008

Farion Cochrane 2009 (Review of 2002)Singer AJEM 2008Beam, JAT 2008Godin Md Qc 2006Young MJA 2005www.rch.org.au/clinicalguide

Indications ≤ 5 cm Clean Straight, low tension Hemostasis achieved Extreme care if around the eyes

Farion Cochrane 2009Singer AJEM 2008Beam, JAT 2008Godin Md Qc 2006Young MJA 2005www.rch.org.au/clinicalguide

Esteban’s facial laceration:Glue/tissue adhesives

Contraindications Allergy Mucosal surfaces Contaminated wound, infected, bites or delay in closure Tension, articulation Active bleeding

Singer AJEM 2008Beam, JAT 2008Young MJA 2005www.rch.org.au/clinicalguide

Esteban’s facial laceration:Glue/tissue adhesives

Esteban, ready to go

www.mja.com.au

Case 2: Elsa, 4 yo, meets the door corner…

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Elsa’s deep laceration: Evaluation

Exclude others injuries Exclude foreign body Confirm adequate immunization Baseline interventions: ‘‘The Essentials’’

Distraction + Positioning Topical anesthetics Absorbable sutures Might require procedural sedation and analgesia

Young MJA 2005www.rch.org.au/clinicalguide: Lacerationswww.childrensmn.org/services/care-specialities-deparments/pain-program/childrens-comfort-promise/

Fein Pediatrics 2012Young MJA 2005

Elsa’s deep laceration: The Essentials

For sutures… Keep child in contact with his/her parent Preparation Distraction, Childlife specialist Systemic analgesic

Simple analgesics Opiate ± PSA may be require: Eg Nitrous, IN Fenta/midaz

Gain their trust!

Elsa’s deep laceration: Local anesthetic- LET, lidocaine 1%

LET gel Often is enough to reach adequate analgesia for suturing

Lidocaine 1% ± adrenaline, infiltrated in woundIndications Complement to LET gel As first line if urgent repair required

Fein Pediatrics 2012Nicks IJEM 2010Cepeda Cochrane 2010Godin Md Qc 2006www.urgencehsj.ca

Elsa’s deep laceration: Local anesthetic- LET, lidocaine 1%

Lidocaine 1% ± adrenaline, infiltrated in woundContraindications Allergy

Maximal doses With adrenaline: 7mg/kg (lidocaine 1%: 10mg/mL then 0.7 mL/kg max) Without adrenaline: 4.5mg/kg (lidocaine 1%: 10mg/mL then 0.5mL/kg max)

Fein Pediatrics 2012Nicks IJEM 2010Cepeda Cochrane 2010Godin Md Qc 2006www.urgencehsj.ca

Lidocaine 1%- Pain at injection reduced if: After LET gel (or EMLA) Addition of bicarbonate (v. important if lido w adrenaline = very acidic)

Add bic 8.4% to lidocaine 1% ± adrenaline with a 1:10 proportion Withdraw 1mL of bicarbonate 8.4%, add 10mL of lidocaine 1% ± adrenaline

for a total of 11mL solution Warm solution to body temperature (rub vial between hands) Slow injection Needle 27-30 g Within the wound

Elsa’s deep laceration: Local anesthetic- LET, lidocaine 1%

Fein Pediatrics 2012Frank Can J Plas Surg 2012Hogan An Emerg med 2011Nicks IJEM 2010Cepeda Cochrane 2010Godin Md Qc 2006www.urgencehsj.ca

Absorbable Sutures Indications Always prioritize absorbable sutures in pediatric patients

Be careful if Articulations Under tension

Luck PEC 2008 and 2013Al Abdullah PEC 2007Godin Md Qc 2006Karounis Acad Emerg Md 2004www.urgencehsj.ca

Elsa’s deep laceration: Suturing

Elsa, Vers un nouveau départ

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www.urgencehsj.caBASELINE INTERVENTIONS: THE ESSENTIALS -KEEP CHILD IN CONTACT WITH PARENT-PREPARATION AND DISTRACTION-LET GEL FROM TRIAGE-GLUE!-IF IMPOSSIBLE: -ABSORBABLE SUTURES ±LIDOCAINE 1% WITH BICARBONATE ±SYSTEMIC ANALGESICS ±PSA

Comfort in pediatric minor proceduresPain free laceration repair for Esteban and Elsa