Thursday, February 16, 2017

pediatric minor procedures

Procedures  
;Bradley D. McCammack MD
Harriet Lane Handbook, The, Chapter 3, 27-60


I
General Guidelines
Consent 
Before performing any procedure, it is crucial to obtain informed consent from the parent or guardian by explaining the procedure, the indications, any risks involved, and any alternatives. Obtaining consent for life-saving emergency procedures is unnecessary.

Risks
1. 
All invasive procedures involve pain and risk for infection and bleeding. Specific complications are listed by procedure.
2. 
Sedation and analgesia should be planned in advance, and the risks of such explained to the parent and/or patient as appropriate. In general, 1% lidocaine buffered with sodium bicarbonate is adequate for local analgesia. See Chapter 6 for Analgesia and Procedural Sedation guidelines. Also see the "AAP Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures." 1
3. 
Universal precautions should be followed for all patient contact that exposes the health care provider to blood, amniotic fluid, pericardial fluid, pleural fluid, synovial fluid, cerebrospinal fluid (CSF), semen, or vaginal secretions.
4. 
Proper sterile technique is essential to achieving good wound closure, decreasing transmittable diseases, and preventing wound contamination.
II
Blood Sampling
A. 
Heelstick and Fingerstick 2
1. 
Indications: Blood sampling in infants for laboratory studies unaffected by hemolysis
2. 
Complications: Infection, bleeding, osteomyelitis
3. 
Procedure:
a. 
Warm heel or finger.
b. 
Clean with alcohol.
(1) 
Puncture heel using a lancet on the lateral part of the heel, avoiding the posterior area.
(2) 
Puncture finger using a lancet on the palmar lateral surface of the finger near the tip.
c. 
Wipe away the first drop of blood, then collect the sample using a capillary tube or container.
d. 
Alternate between squeezing blood from the leg toward the heel (or from the hand toward the finger) and then releasing the pressure for several seconds.
B. 
External Jugular Puncture 3
1. 
Indications: Blood sampling in patients with inadequate peripheral vascular access or during resuscitation
2. 
Complications: Infection, bleeding, pneumothorax
3. 
Procedure . 
Restrain infant securely. Place infant with head turned away from side of blood sampling. Position with towel roll under shoulders or with head over side of bed to extend neck and accentuate the posterior margin of the sternocleidomastoid muscle on the side of the venipuncture.
b. 
Prepare area in a sterile fashion.
c. 
The external jugular vein will distend if its most proximal segment is occluded or if the child cries. The vein runs from the angle of the mandible to the posterior border of the lower third of the sternocleidomastoid muscle.
d. 
With continuous negative suction on the syringe, insert the needle at about a 30-degree angle to the skin. Continue as with any peripheral venipuncture.
e. 
Apply a sterile dressing, and put pressure on the puncture site for 5 minutes.
Open full size image
FIGURE 3-1
External jugular cannulation.
(From Dieckmann R, Fiser D, Selbst S . Pediatric Emergency and Critical Care Procedures. St. Louis: Mosby, 1997.)
C. 
Femoral Artery and Femoral Vein Puncture 34
1. 
Indications: Venous or arterial blood sampling in patients with inadequate vascular access or during resuscitation.
2. 
Contraindications: Femoral puncture is particularly hazardous in neonates and not recommended in this age group. There is also a risk in children for trauma to the femoral head and joint capsule. Avoid femoral punctures in children who have thrombocytopenia or coagulation disorders and in those who are scheduled for cardiac catheterization.
3. 
Complications: Infection, bleeding, hematoma of femoral triangle, thrombosis of vessel, osteomyelitis, septic arthritis of hip.
4. 
Procedure 
a. 
Hold child securely in frog-leg position with the hips flexed and abducted. It may help to place a roll under the hips.
b. 
Prepare area in sterile fashion.
c. 
Locate femoral pulse just distal to the inguinal crease (note that vein is medial to pulse). Insert needle 2 cm distal to the inguinal ligament and 0.5 to 0.75 cm into the groin. Aspirate while maneuvering the needle until blood is obtained. 
NOTE: The right femoral vein is easier to cannulate than left owing to straighter path to inferior vena cava.
d. 
Apply direct pressure for minimum of 5 minutes.
Radial Artery Puncture and Catheterization 34
1. 
Indications: Arterial blood sampling or frequent blood gases and continuous blood pressure monitoring in an intensive care setting.
2. 
Complications: Infection, bleeding, occlusion of artery by hematoma or thrombosis, ischemia if ulnar circulation is inadequate.
3. 
Procedure:
a. 
Before procedure, test adequacy of ulnar blood flow with the Allen test. Clench the hand while simultaneously compressing ulnar and radial arteries. The hand will blanch. Release pressure from the ulnar artery, and observe the flushing response. Procedure is safe to perform if entire hand flushes.
b. 
Locate the radial pulse. It is optional to infiltrate the area over the point of maximal impulse with lidocaine. Avoid infusion into the vessel by aspirating before infusing. Prepare the site in sterile fashion.
(1) 
Puncture: Insert butterfly needle attached to a syringe at a 30- to 60-degree angle over the point of maximal impulse. Blood should flow freely into the syringe in a pulsatile fashion. Suction may be required for plastic tubes. Once the sample is obtained, apply firm, constant pressure for 5 minutes and then place a pressure dressing on the puncture site.
(2) 
Catheter placement: Secure the patient's hand to an arm board. Leave the fingers exposed to observe any color changes. Prepare the wrist with sterile technique and infiltrate over the point of maximal impulse with 1% lidocaine. Make a small skin puncture over the point of maximal impulse with a needle, then discard the needle. Insert an intravenous (IV) catheter with its needle through the puncture site at a 30-degree angle to the horizontal. Pass the needle and catheter through the artery to transfix it, then withdraw the needle. Very slowly, withdraw the catheter until free flow of blood is noted, then advance the catheter and secure in place using sutures or tape. Seldinger technique using a guidewire can also be used. Apply a sterile dressing. Infuse heparinized isotonic fluid (per protocol) at 1 mL/hr. A pressure transducer may be attached to monitor blood pressure. 
NOTE: Do not infuse any medications, blood products, or hypotonic or hypertonic solutions through an arterial line.
(3) 
Suggested size of arterial catheters based on weight:
(a) 
Infant (<10 kg): 24G or 2.5Fr, 2.5 cm
(b) 
Child (10 to 40 kg): 22G or 2.4Fr, 2.5 cm
(c) 
Adolescent (>40 kg): 20G
4. 
A video on radial artery catheterization is available on the New England Journal of Medicine's website.
E. 
Posterior Tibial and Dorsalis Pedis Artery Puncture 4
1. 
Indications: Arterial blood sampling when radial artery puncture is unsuccessful or inaccessible.
2. 
Complications: Infection, bleeding, ischemia if circulation is inadequate
3. 
Procedure (see Section II.D for technique):
a. 
Posterior tibial artery: Puncture the artery posterior to medial malleolus while holding foot in dorsiflexion.
b. 
Dorsalis pedis artery: Puncture the artery at dorsal midfoot between first and second toes while holding foot in plantar flexion.
III
Vascular Access
A. 
Peripheral Intravenous Placement
1. 
Indications: To obtain access to peripheral venous circulation to deliver fluid, medications, or blood products.
2. 
Complications: Thrombosis, infection.
3. 
Procedure:
a. 
Choose IV placement site and prepare with alcohol.
b. 
Apply tourniquet and then insert IV catheter, bevel up, at angle almost parallel to the skin, advancing until a flash of blood is seen in the catheter hub. Advance the plastic catheter only, remove the needle, and secure the catheter.
c. 
After removing tourniquet, attach T connector filled with saline to the catheter, flush with normal saline (NS) to ensure patency of the IV line.
B. 
Central Venous Catheter Placement 3567
1. 
Indications: To obtain emergency access to central venous circulation, monitor central venous pressure, deliver high-concentration parenteral nutrition or prolonged IV therapy, or infuse blood products or large volumes of fluid.
2. 
Complications: Infection, bleeding, arterial or venous perforation, pneumothorax, hemothorax, thrombosis, catheter fragment in circulation, air embolism.
3. 
Ultrasound guidance: Quickly becoming standard among health care facilities to aid placement of central venous catheters. It has been shown to reduce failure and complication rates when effectively implemented.
4. 
Access sites:
a. 
External jugular vein
b. 
Subclavian vein: Least common site in children owing to increased complications
c. 
Internal jugular vein: Contraindicated with elevated intracranial pressure
d. 
Femoral vein: Contraindicated with severe abdominal trauma
5. 
Procedure: Seldinger technique
a. 
Secure patient, prepare site, and drape according to the following guidelines for sterile technique 7 :
(1) 
Wash hands.
(2) 
Wear hat, mask, eye shield, sterile gloves, and sterile gown.
(3) 
Prep procedure site for 30 seconds (chlorhexidine), and allow to dry for an additional 30 seconds (in groin, scrub for 2 minutes, and allow to dry for 1 minute).
(4) 
Use sterile technique to drape the site.
b. 
Insert needle, applying negative pressure to locate vessel.
c. 
When there is blood return, insert a guidewire through the needle into the vein. Watch cardiac monitor for ectopy.
d. 
Remove the needle, firmly holding the guidewire.
e. 
Slip a catheter that has been preflushed with sterile saline over the wire into the vein in a twisting motion. The entry site may be enlarged with a small skin incision or dilator. Pass the entire catheter over the wire until the hub is at the skin surface. Slowly remove the wire, secure the catheter by suture, and attach IV infusion.
f. 
Apply a sterile dressing over the site.
g. 
For neck vessels, obtain a chest radiograph to rule out pneumothorax.
h. 
A video on central venous catheterization is available on the New England Journal of Medicine's website.
6. 
Approach:
a. 
External jugular
Place patient in 15- to 20-degree Trendelenburg position. Turn the head 45 degrees to the contralateral side. Enter the vein at the point where it crosses the sternocleidomastoid muscle.
b. 
Internal jugular
Place patient in 15- to 20-degree Trendelenburg position. Hyperextend the neck to tense the sternocleidomastoid muscle, and turn head away from the site of line placement. Palpate the sternal and clavicular heads of the muscle, and enter at the apex of the triangle formed. An alternative landmark for puncture is halfway between the sternal notch and tip of the mastoid process. Insert the needle at a 30-degree angle to the skin, and aim toward the ipsilateral nipple. When blood flow is obtained, continue with Seldinger technique. Right side is preferable because of straight course to right atrium, absence of thoracic duct, and lower pleural dome on right side. The internal jugular vein runs lateral to the carotid artery. 

Subclavian vein ( Fig. 3-5 ): Position child in Trendelenburg position with a towel roll under thoracic spine to hyperextend the back. Aim the needle under the distal third of the clavicle toward the sternal notch. When blood flow is obtained, continue with Seldinger technique.
(1) 
A video on subclavian venous catheter placement is available on the New England Journal of Medicine's website.


d. 
Femoral vein ( Fig. 3-6 ): Hold child securely with the hip flexed and abducted. Locate the femoral pulse just distal to the inguinal crease. In infants, vein is 5 to 6 mm medial to arterial pulse. In adolescents, vein is usually 10 to 15 mm medial to the pulse. Place the thumb of the nondominant hand on the femoral artery. Insert the needle medial to the thumb. The needle should enter the skin 2 to 3 cm distal to the inguinal ligament at a 30-degree angle to avoid entering the abdomen. When blood flow is obtained, continue with Seldinger technique.
(1) 
A video on femoral venous catheterization is available on the New England Journal of Medicine's website.

C. 
Intraosseous (IO) Infusion 34 \\
1. 
Indications: Obtain emergency access in children during life-threatening situations. This is very useful during cardiopulmonary arrest, shock, burns, and life-threatening status epilepticus. IO line can be used to infuse medications, blood products, or fluids. The IO needle should be removed once adequate vascular access has been established.
2. 
Complications:
a. 
Complications are rare, particularly with correct technique. Frequency of complications increases with prolonged infusions.
b. 
Extravasation of fluid from incomplete cortex penetration, infection, bleeding, osteomyelitis, compartment syndrome, fat embolism, fracture, epiphyseal injury.
3. 
Sites of entry (in order of preference):
a. 
Anteromedial surface of the proximal tibia, 2 cm below and 1 to 2 cm medial to the tibial tuberosity on the flat part of the bone (see Fig. 3-7 )
b. 
Distal femur 3 cm above the lateral condyle in the midline
c. 
Medial surface of the distal tibia 1 to 2 cm above the medial malleolus (may be a more effective site in older children)
d. 
Anterosuperior iliac spine at an angle of 90 degrees to the long axis of the body
4. 
Procedure:
a. 
Prepare the selected site in sterile fashion if situation allows.
b. 
If the child is conscious, anesthetize the puncture site down to the periosteum with 1% lidocaine (optional in emergency situations).
c. 
Choose between manual IO or drill-powered IO insertion device:
(1) 
For manual IO needle: Insert a 15- to 18-gauge IO needle perpendicular to skin at angle away from epiphyseal plate, and advance to the periosteum. With a boring rotary motion, penetrate through the cortex until there is a decrease in resistance, indicating that you have reached the marrow. The needle should stand firmly without support. Secure the needle carefully.
(2) 
For drill-powered IO needle: Enter skin with the needle perpendicular to the skin, as with the manual needle, and gently power the drill or simply press the needle until you meet the periosteum. Apply easy pressure while gently depressing the drill trigger until you feel a "pop" or a sudden decrease in resistance. Remove the drill while holding the needle steady to ensure stability prior to securing the needle. Use an EZ-IO AD for patients >40 kg, and use EZ-IO PD for patients >6 kg and <40 kg.
d. 
Remove the stylet and attempt to aspirate marrow. (Note that it is not necessary to aspirate marrow.) Flush with 10 to 20 mL of crystalloid solution. Observe for fluid extravasation. Marrow can be sent for determination of glucose levels, chemistries, blood type and cross-match, hemoglobin, blood gas analysis, and cultures.
e. 
Attach standard IV tubing. Any crystalloid, blood product, or drug that may be infused into a peripheral vein may also be infused into the IO space, but increased pressure (through pressure bag or push) is necessary for infusion. There is a high risk for obstruction if continuous high-pressure fluids are not flushed through the IO needle.
5. 
A video on IO catheter placement is available on the New England Journal of Medicine's website.
Open full size image
FIGURE 3-7
Intraosseous needle placement using standard anterior tibial approach. Insertion point is in the midline on medial flat surface of anterior tibia, 1 to 3 cm (2 fingerbreadths) below tibial tuberosity.
(From Dieckmann R, Fiser D, Selbst S . Pediatric Emergency and Critical Care Procedures. St. Louis: Mosby, 1997.)
D. 
Umbilical Artery (UA) and Umbilical Vein (UV) Catheterization 3
1. 
Indications: Vascular access (via UV), blood pressure (via UA), and blood gas (via UA) monitoring in critically ill neonates.
2. 
Complications: Infection, bleeding, hemorrhage, perforation of vessel; thrombosis with distal embolization; ischemia or infarction of lower extremities, bowel, or kidney; arrhythmia if catheter is in the heart; air embolus.
3. 
Caution: UA catheterization should never be performed if omphalitis or peritonitis is present. It is contraindicated in the presence of possible necrotizing enterocolitis or intestinal hypoperfusion.
4. 
Line placement:
a. 
Arterial line: Low line vs. high line.
(1) 
Low line: Tip of catheter should lie just above the aortic bifurcation between L3 and L5. This avoids renal and mesenteric arteries near L1, possibly decreasing the incidence of thrombosis or ischemia.
(2) 
High line: Tip of catheter should be above the diaphragm between T6 and T9. A high line may be recommended in infants weighing less than 750 g, in whom a low line could easily slip out.
b. 
UV catheters should be placed in the inferior vena cava above the level of the ductus venosus and the hepatic veins and below the level of the right atrium.
c. 
Catheter length: Determine the length of catheter required using either a standardized graph or the regression formula. Add length for the height of the umbilical stump.
(1) 
Standardized graph: Determine the shoulder-umbilical length by measuring the perpendicular line dropped from the tip of the shoulder to the level of the umbilicus. Use the graphto determine the arterial catheter length, and the graph in  determine venous catheter length. 
Open full size image
FIGURE 3-8
Umbilical artery catheter length.
Open full size image
FIGURE 3-9
Umbilical vein catheter length.
(2) 
Birth weight (BW) regression formula:
Low line:UA catheter length(cm)=BW(kg)+7.Low line:UA catheter length(cm)=BW(kg)+7.
High line:UA catheter length(cm)=[3×BW(kg)]+9High line:UA catheter length(cm)=[3×BW(kg)]+9
UV catheter length(cm)=[0.5×high line UA(cm)]+1UV catheter length(cm)=[0.5×high line UA(cm)]+1
NOTE: Formula may not be appropriate for infants who are small for gestational age (SGA) or large for gestational age (LGA).
5. 
Procedure for UA line
a. 
Determine the length of the catheter to be inserted for either high (T6–T9) or low (L3–L5) position.
b. 
Restrain infant. Maintain the infant's temperature during the procedure. Prepare and drape the umbilical cord and adjacent skin using sterile technique.
c. 
Flush the catheter with sterile saline solution before insertion. Ensure there are no air bubbles in the catheter or attached syringe.
d. 
Place sterile umbilical tape around the base of the cord. Cut through the cord horizontally about 1.5 to 2 cm from the skin; tighten the umbilical tape to prevent bleeding.
e. 
Identify the one large, thin-walled umbilical vein and two smaller, thick-walled arteries. Use one tip of open, curved forceps to gently probe and dilate one artery. Use both points of closed forceps, and dilate artery by allowing forceps to open gently.
f. 
Grasp the catheter 1 cm from its tip with toothless forceps, and insert the catheter into the lumen of the artery. Aim the tip toward the feet, and gently advance the catheter to the desired distance. Do not force. If resistance is encountered, try loosening umbilical tape, applying steady and gentle pressure, or manipulating the angle of the umbilical cord to skin. Often the catheter cannot be advanced because of creation of a "false luminal tract." There should be good blood return when the catheter enters the iliac artery.
g. 
Radiographically confirm catheter tip position. Secure catheter with a suture through the cord, a marker tape, and a tape bridge. The catheter may be pulled back but not advanced once the sterile field is broken.
h. 
Observe for complications: Blanching or cyanosis of lower extremities, perforation, thrombosis, embolism, or infection. If any complications occur, the catheter should be removed.
i. 
Use isotonic fluids, which contain 0.5 units/mL of heparin. Never use hypo-osmolar fluids in the UA. 
NOTE: There are no definitive guidelines on feeding with a UA catheter in place. There is concern (up to 24 hours after removal) that the UA catheter or thrombus may interfere with intestinal perfusion. A risk-to-benefit assessment should be individualized.
Procedure for UV line
a. 
Follow steps "a" through "d" for UA catheter placement, but determine catheter length using
b. 
Isolate the thin-walled umbilical vein, clear thrombi with forceps, and insert catheter, aiming the tip toward the right shoulder. Gently advance the catheter to the desired distance. Do not force. If resistance is encountered, try loosening the umbilical tape, applying steady and gentle pressure, or manipulating the angle of the umbilical cord to skin. Resistance is commonly met at the abdominal wall and again at the portal system. Do not infuse anything into liver.
c. 
Radiographically confirm catheter tip position. Secure catheter as described in step "g" for UA placement.
IV
Body Fluid Sampling
A. 
Lumbar Puncture 34
1. 
Indications: Examination of spinal fluid for suspected infection or malignancy, instillation of intrathecal chemotherapy, or measurement of opening pressure.
2. 
Complications: Local pain, infection, bleeding, spinal fluid leak, hematoma, spinal headache, acquired epidermal spinal cord tumor (caused by implantation of epidermal material into spinal canal if no stylet is used on skin entry).
3. 
Cautions and contraindications:
a. 
Increased intracranial pressure (ICP): Before lumbar puncture (LP), perform funduscopic examination. Presence of papilledema, retinal hemorrhage, or clinical suspicion of increased ICP may be contraindications to the procedure. A sudden drop in intraspinal pressure by rapid release of CSF may cause fatal herniation. If LP is to be performed, proceed with extreme caution. Computed tomography (CT) may be indicated before LP if there is suspected intracranial bleeding, focal mass lesion, or increased ICP. A normal CT scan does not rule out increased ICP but usually excludes conditions that may put the patient at risk for herniation. Decision to obtain CT should not delay appropriate antibiotic therapy if indicated.
b. 
Bleeding diathesis: Platelet count >50,000/mm 3 is desirable before LP, and correction of any clotting factor deficiencies can minimize risk for bleeding and subsequent cord or nerve root compression.
c. 
Overlying skin infection may result in inoculation of CSF with organisms.
d. 
LP should be deferred in an unstable patient, and appropriate therapy should be initiated, including antibiotics if indicated.
4. 
Procedure:
a. 
Apply local anesthetic cream if sufficient time is available.
b. 
Position child in either the sitting position or lateral recumbent position with hips, knees, and neck flexed. Keep shoulders and hips aligned (perpendicular to examining table in recumbent position) to avoid rotating the spine. Do not compromise a small infant's cardiorespiratory status with positioning. 
c. 
Locate the desired intervertebral space (either L3-4 or L4-5) by drawing an imaginary line between the top of the iliac crests.
d. 
Prepare the skin in sterile fashion. Drape conservatively to make monitoring the infant possible. Use a 20G to 22G spinal needle with stylet (1.5 inch for children <12 years, 3.5 inches for children ≥12 years). A smaller-gauge needle will decrease the incidence of spinal headache and CSF leak.
e. 
Overlying skin and interspinous tissue can be anesthetized with 1% lidocaine using a 25G needle.
f. 
Puncture the skin in the midline just caudad to the palpated spinous process, angling slightly cephalad toward the umbilicus. Advance several millimeters at a time, and withdraw stylet frequently to check for CSF flow. Needle may be advanced without the stylet once it is completely through the skin. In small infants, one may not feel a change in resistance or "pop" as the dura is penetrated.
g. 
If resistance is met initially (you hit bone), withdraw needle to the skin surface and redirect angle slightly.
h. 
Send CSF for appropriate studies (see Chapter 27 for normal values). Send the first tube for culture and Gram stain, second tube for measurement of glucose and protein levels, and last tube for cell count and differential. An additional tube can be collected for viral cultures, polymerase chain reaction (PCR), or CSF metabolic studies if indicated. If subarachnoid hemorrhage or traumatic tap is suspected, send the first and fourth tubes for cell count, and ask the laboratory to examine the CSF for xanthochromia.
i. 
Accurate measurement of CSF pressure can be made only with the patient lying quietly on his or her side in an unflexed position. It is not a reliable measurement in the sitting position. Once free flow of spinal fluid is obtained, attach the manometer and measure CSF pressure. Opening pressure is recorded as the level at which CSF is steady.
5. 
A video on lumbar punctures is available on the New England Journal of Medicine's website.
B. 
Chest Tube Placement and Thoracentesis 36
1. 
Indications: Evacuation of a pneumothorax, hemothorax, chylothorax, large pleural effusion, or empyema for diagnostic or therapeutic purposes.
2. 
Complications: Infection, bleeding, pneumothorax, hemothorax, pulmonary contusion or laceration, puncture of diaphragm, spleen, or liver, or bronchopleural fistula.
3. 
Procedure: Needle decompression. 
NOTE: For tension pneumothoraces, it is imperative to attempt decompression quickly by inserting a large-bore needle (14G–22G, based on size) in the anterior second intercostal space in the midclavicular line. Insert needle over superior aspect of rib margin to avoid vascular structures.
a. 
When pleural space is entered, attach catheter to a three-way stopcock and syringe, and aspirate air.
b. 
Subsequent insertion of a chest tube is still necessary.
4. 
Procedure ( Fig. 3-13 ): Chest tube insertion. 
Open full size image
FIGURE 3-13
Technique for insertion of chest tube. ICS, Intercostal space; NV, neurovascular; R-VI, sixth rib.
( Modified from Fleisher G, Ludwig S . Pediatric Emergency Medicine. 3rd ed. Baltimore: Williams & Wilkins, 2000.)
(See inside front cover for chest tube sizes.)
a. 
Position child supine or with affected side up and arm restrained over the head.
b. 
Point of entry is the third to fifth intercostal space in the mid- to anterior axillary line, usually at the level of the nipple (avoid breast tissue).
c. 
Prepare and drape in sterile fashion.
d. 
Patient may require sedation (see Chapter 6 ). Locally anesthetize skin, subcutaneous tissue, periosteum of rib, chest wall muscles, and pleura with 1% lidocaine.
e. 
Make sterile 1- to 3-cm incision one intercostal space below desired insertion point, and bluntly dissect with a hemostat through tissue layers until the superior portion of the rib is reached, avoiding the neurovascular bundle on the inferior portion of the rib.
f. 
Push hemostat over the top of the rib, through pleura, and into pleural space. Enter the pleural space cautiously and not deeper than 1 cm. Spread hemostat to open, place chest tube in clamp, and guide through entry site to desired distance.
g. 
For a pneumothorax, insert tube anteriorly toward the apex. For a pleural effusion, direct tube inferiorly and posteriorly.
h. 
Secure chest tube with purse-string sutures in which suture is first tied at the skin, then wrapped around the tube once and tied at the tube.
i. 
Attach to a drainage system with 20 to 30 cm H 2 O pressure.
j. 
Apply a sterile occlusive dressing.
k. 
Confirm position and function with chest radiograph.
5. 
A video on chest tube insertion is available on the New England Journal of Medicine's website.
6. 
Procedure: Thoracentesis ( Fig. 3-14 )
a. 
Confirm fluid in pleural space by clinical examination and radiographs or ultrasonography.
b. 
If possible, place child in sitting position leaning over table; otherwise place supine.
c. 
Point of entry is usually in the seventh intercostal space and posterior axillary line.
d. 
Prepare and drape area in sterile fashion.
e. 
Anesthetize skin, subcutaneous tissue, rib periosteum, chest wall, and pleura with 1% lidocaine.
f. 
Advance an 18G–22G IV catheter or large-bore needle attached to a syringe onto the rib, and then "walk" over the superior aspect into the pleural space while providing steady negative pressure; often a popping sensation is generated. Be careful to not advance too far into the pleural cavity. If an IV or pigtail catheter (with guidewire) is used, the soft catheter may be advanced into the pleural space, aiming downward.
g. 
Attach syringe and stopcock device to remove fluid for diagnostic studies and symptomatic relief (see Chapter 27 for evaluation of pleural fluid).
h. 
After removing needle or catheter, place an occlusive dressing over the site and obtain a chest radiograph to rule out pneumothorax.
Open full size image
FIGURE 3-14
Thoracentesis. ICS, Intercostal space.
( Modified from Fleisher G, Ludwig S . Pediatric Emergency Medicine. 3rd ed. Baltimore: Williams & Wilkins, 2000.)
7. 
A video on thoracentesis is available on the New England Journal of Medicine's website.
C. 
Pericardiocentesis 36
1. 
Indications: To obtain pericardial fluid in cardiac tamponade emergently or nonemergently for diagnostic or therapeutic purposes.
2. 
Complications: Bleeding, infection, puncture of cardiac chamber, cardiac dysrhythmia, hemopericardium or pneumopericardium, pneumothorax, hemothorax, cardiac arrest, death.
3. 
Procedure
a. 
Unless contraindicated, provide sedation and/or analgesia for the patient. Monitor electrocardiogram (ECG).
b. 
Place patient at a 30-degree angle (reverse Trendelenburg). Have patient secured.
c. 
Prepare and drape puncture site in sterile fashion. A drape across upper chest is unnecessary and may obscure important landmarks.
d. 
Anesthetize puncture site with 1% lidocaine.
e. 
Insert an 18G or 20G needle just to the left of the xiphoid process, 1 cm inferior to the bottom rib at about a 45-degree angle to the skin.
f. 
While gently aspirating, advance needle toward the patient's left shoulder until pericardial fluid is obtained.
g. 
Upon entering the pericardial space, clamp the needle with a hemostat at the skin edge to prevent further penetration. Attach a 30-mL syringe with a stopcock.
h. 
Gently and slowly remove the fluid. Rapid withdrawal of pericardial fluid can result in shock or myocardial insufficiency.
i. 
Send fluid for appropriate laboratory studies (see Chapter 27 ).
j. 
In nonemergent conditions, this is best performed under two-dimensional echocardiographic guidance.
4. 
A video on pericardiocentesis is available on the New England Journal of Medicine's website.
D. 
Paracentesis 4
1. 
Indications: Percutaneous removal of intraperitoneal fluid for diagnostic or therapeutic purposes.
2. 
Complications: Bleeding, infection, puncture of viscera.
3. 
Cautions:
a. 
Do not remove a large amount of fluid too rapidly; hypovolemia and hypotension may result from rapid fluid shifts.
b. 
Avoid scars from previous surgery; localized bowel adhesions increase the chances of entering a viscus in these areas.
c. 
Urinary bladder should be empty to avoid perforation.
d. 
Never perform paracentesis through an area of cellulitis.
4. 
Procedure:
a. 
Prepare and drape abdomen as for a surgical procedure. Anesthetize puncture site.
b. 
With patient in semisupine, sitting, or lateral decubitus position, insert a 16G to 22G IV catheter attached to a syringe in midline 2 cm below umbilicus. In neonates, insert just lateral to rectus muscle in the right or left lower quadrants, a few centimeters above inguinal ligament.
c. 
Aiming cephalad, insert needle at a 45-degree angle while one hand pulls the skin caudally until entering the peritoneal cavity. This creates a Z tract when the skin is released and the needle removed. Apply continuous negative pressure.
d. 
Once fluid appears in the syringe, remove introducer needle and leave catheter in place. Attach a stopcock and aspirate slowly until an adequate amount of fluid has been obtained for studies or symptomatic relief.
e. 
If, on entering the peritoneal cavity, air is aspirated, withdraw the needle immediately. Aspirated air indicates entrance into a hollow viscus. (In general, penetration of a hollow viscus during paracentesis does not lead to complications.) Repeat paracentesis with sterile equipment.
f. 
Send fluid for appropriate laboratory studies
E. 
Urinary Bladder Catheterization 4
1. 
Indications: To obtain urine for urinalysis and culture sterilely and to accurately monitor hydration status.
2. 
Complications: Hematuria, infection, trauma to urethra or bladder, intravesical knot of catheter (rarely occurs).
3. 
Procedure:
a. 
Infant/child should not have voided within 1 hour of procedure. 
NOTE: Catheterization is contraindicated in pelvic fractures, known trauma to the urethra, or blood at the meatus.
b. 
Prepare the urethral opening using sterile technique.
c. 
In males, apply gentle traction to the penis to straighten the urethra. In uncircumcised male infants, expose the meatus with gentle retraction of the foreskin. The foreskin has to be retracted only far enough to visualize the meatus.
d. 
Gently insert a lubricated catheter into the urethra. Slowly advance catheter until resistance is met at the external sphincter. Continued pressure will overcome this resistance, and the catheter will enter the bladder. In girls, the urethral orifice may be difficult to visualize, but it is usually immediately anterior to the vaginal orifice. Only a few centimeters of advancement is required to reach the bladder in girls. In boys, insert a few centimeters longer than the shaft of the penis.
e. 
Carefully remove the catheter once specimen is obtained, and cleanse skin of iodine.
f. 
If indwelling Foley catheter is inserted, inflate balloon with sterile water as indicated on bulb, then connect catheter to drainage tubing attached to urine drainage bag. Secure catheter tubing to inner thigh.
F. 
Suprapubic Bladder Aspiration 3
1. 
Indications: To sterilely obtain urine for urinalysis and culture in children younger than 2 years (avoid in children with genitourinary tract anomalies, coagulopathy, or intestinal obstruction). Bypasses distal urethra, thereby minimizing risk for contamination.
2. 
Complications: Infection (cellulitis), hematuria (usually microscopic), intestinal perforation.
3. 
Procedure
a. 
Anterior rectal pressure in girls or gentle penile pressure in boys may be used to prevent urination during the procedure. Child should not have voided within 1 hour of procedure.
b. 
Restrain infant in the supine, frog-leg position. Prepare suprapubic area in sterile fashion.
c. 
The site for puncture is 1 to 2 cm above the symphysis pubis in the midline. Use a syringe with a 22G, 1-inch needle, and puncture at a 10- to 20-degree angle to the perpendicular, aiming slightly caudad.
d. 
Gently exert suction as the needle is advanced until urine enters syringe. The needle should not be advanced more than 1 inch. Aspirate urine with gentle suction.
e. 
Cleanse skin of iodine.
Open full size image
Open full size image
FIGURE 3-17
Landmarks for suprapubic bladder aspiration.
(From Dieckmann R, Fiser D, Selbst S . Pediatric Emergency and Critical Care Procedures. St. Louis: Mosby, 1997.)
G. 
Soft Tissue Aspiration 8
1. 
Indications: Cellulitis that is unresponsive to initial standard therapy, recurrent cellulitis or abscesses, immunocompromised patients in whom organism recovery is necessary and may affect antimicrobial therapy
2. 
Complications: Pain, infection, bleeding
3. 
Procedure:
a. 
Select site to aspirate at point of maximal inflammation (more likely to increase recovery of causative agent than leading edge of erythema or center). 8
b. 
Cleanse area in sterile fashion.
c. 
Local anesthesia with 1% lidocaine is optional.
d. 
Fill tuberculin syringe with 0.1 to 0.2 mL of nonbacteriostatic sterile saline, and attach to needle.
e. 
Using 18G or 20G needle (22G for facial cellulitis), advance to appropriate depth and apply negative pressure while withdrawing needle.
f. 
Send fluid from aspiration for Gram stain and cultures. If no fluid is obtained, needle can be streaked on agar plate. Consider acid-fast bacillus (AFB) and fungal stains in immunocompromised patients.
V
Immunization and Medication Administration 4
A. 
Subcutaneous Injections
1. 
Indications: Immunizations and other medications
2. 
Complications: Bleeding, infection, allergic reaction, lipohypertrophy or lipoatrophy after repeated injections
3. 
Procedure:
a. 
Locate injection site: Upper outer arm or outer aspect of upper thigh.
b. 
Cleanse skin with alcohol.
c. 
Insert 0.5-inch, 25G or 27G needle into subcutaneous layer at a 45-degree angle to the skin. Aspirate for blood, then inject medication.
B. 
Intramuscular Injections
1. 
Indications: Immunizations and other medications
2. 
Complications: Bleeding, infection, allergic reaction, nerve injury
3. 
Cautions:
a. 
Avoid intramuscular (IM) injections in a child with a bleeding disorder or thrombocytopenia.
b. 
Maximum volume to be injected is 0.5 mL in a small infant, 1 mL in an older infant, 2 mL in a school-aged child, and 3 mL in an adolescent.
4. 
Procedure:
a. 
Locate injection site: Anterolateral upper thigh (vastus lateralis muscle) in smaller child or outer aspect of upper arm (deltoid) in older one. The dorsal gluteal region is less commonly used because of risk for nerve or vascular injury. To find the ventral gluteal site, form a triangle by placing your index finger on the anterior iliac spine and your middle finger on the most superior aspect of the iliac crest. The injection should occur in the middle of the triangle formed by the two fingers and the iliac crest.
b. 
Cleanse skin with alcohol.
c. 
Pinch muscle with free hand and insert 1-inch, 23G or 25G needle until hub is flush with skin surface. For deltoid and ventral gluteal muscles, needle should be perpendicular to skin. For anterolateral thigh, needle should be 45 degrees to the long axis of the thigh. Aspirate for blood, then inject medication.
VI
Basic Laceration Repair 3
A. 
Suturing
1. 
Techniques
a. 
Simple interrupted
b. 
Horizontal mattress: Provides eversion of wound edges
c. 
Vertical mattress: For added strength in areas of thick skin or areas of skin movement; provides eversion of wound edges
d. 
Running intradermal: For cosmetic closures
Open full size image
FIGURE 3-18
A–E, Vertical mattress suture. After initial placement of a simple interrupted stitch with a larger bite, make a backhand pass across the wound, taking small superficial bites. When knot is tied, edges of laceration should evert slightly.
(From Dieckmann R, Fiser D, Selbst S . Pediatric Emergency and Critical Care Procedures. St. Louis: Mosby, 1997.)
2. 
Procedure: 
NOTE: Lacerations of the face, lips, hands, genitalia, mouth, or periorbital area may require consultation with a specialist. Ideally, lacerations at increased risk for infection (areas with poor blood supply, contaminated/crush injury) should be sutured within 6 hours of injury. Clean wounds in cosmetically important areas may be closed up to 24 hours after injury in the absence of significant contamination or devitalization. In general, bite wounds should not be sutured except in areas of high cosmetic importance (face). The longer sutures are left in place, the greater the scarring and potential for infection. Sutures in cosmetically sensitive areas should be removed as soon as possible. Sutures in high-tension areas (e.g., extensor surfaces) should stay in longer
a. 
Prepare child for procedure with appropriate sedation, analgesia, and restraint.
b. 
Anesthetize the wound with topical anesthetic or with lidocaine bicarbonate by injecting the anesthetic into the subcutaneous tissues (see Formulary).
c. 
Forcefully irrigate the wound with copious amounts of sterile NS. Use at least 250 mL for smaller superficial wounds and more for larger wounds. This is the most important step in preventing infection. Avoid high-pressure irrigation of deep puncture wounds.
d. 
Prepare and drape the patient for a sterile procedure.
e. 
Debride the wound when indicated. Probe for foreign bodies as indicated. Consider obtaining a radiograph if a radiopaque foreign body was involved in the injury.
f. 
Select suture type for percutaneous closure
g. 
Match layers of injured tissues. Carefully match the depth of the bite taken on each side of the wound when suturing. Take equal bites from both wound edges. Apply slight thumb pressure on the wound edge as the needle is entering the opposite side. Pull the sutures to approximate wound edges, but not too tightly to avoid tissue necrosis. In delicate areas, sutures should be approximately 2 mm apart and 2 mm from the wound edge. Larger bites are acceptable where cosmesis is less important. 3
h. 
When suturing is complete, apply topical antibiotic and sterile dressing. If laceration is in proximity of a joint, splinting of the affected area to limit mobility often speeds healing and prevents wound separation.
i. 
Check wounds at 48 to 72 hours in cases where wounds are of questionable viability, if wound was packed, or for patients prescribed prophylactic antibiotics. Change dressing at check.
j. 
For hand lacerations, close skin only; do not use subcutaneous stitches. Elevate and immobilize the hand. Consider consulting a hand or plastics specialist.
k. 
Consider the child's need for tetanus prophylaxis for guidelines).
TABLE 3-1
GUIDELINES FOR SUTURE MATERIAL, SIZE, AND REMOVAL
Body Region
Monofilament ∗ (for Superficial Lacerations)
Absorbable † (for Deep Lacerations)
Duration (days)
Scalp
5–0 or 4–0
4–0
5–7
Face
6–0
5–0
3–5
Eyelid
7–0 or 6–0
—
3–5
Eyebrow
6–0 or 5–0
5–0
3–5
Trunk
5–0 or 4–0
3–0
5–7
Extremities
5–0 or 4–0
4–0
7–10
Joint surface
4–0
—
10–14
Hand
5–0
5–0
7
Foot sole
4–0 or 3–0
4–0
7–10
 View full size
∗ Examples of monofilament nonabsorbable sutures: Nylon, polypropylene. Good for the outermost layer of skin. Use 4–5 throws per knot. Polypropylene is good for scalp, eyebrows. 
† Examples of absorbable sutures: Polyglycolic acid and polyglactin 910 (Vicryl). Good for deeper, subcuticular layers.
3. 
A video on basic laceration repair is available on the New England Journal of Medicine's website.
B. 
Skin Staples
1. 
Indications:
a. 
Best for scalp, trunk, extremities
b. 
More rapid application than sutures but can be more painful to remove
c. 
Lower rates of wound infection
2. 
Contraindications:
a. 
Not for areas that require meticulous cosmesis
b. 
Avoid in patients who require magnetic resonance imaging (MRI) or CT
3. 
Procedure:
a. 
Appose wound edges and staple.
b. 
Left in place for the same length of time as sutures
c. 
To remove, use staple remover.
C. 
Tissue Adhesives
1. 
Indications:
a. 
For use with superficial lacerations with clean edges
b. 
Excellent cosmetic results, ease of application, and reduced patient anxiety
c. 
Lower rates of wound infection
2. 
Contraindications:
a. 
Not for use in areas under large amounts of tension (e.g., hands, joints).
b. 
Use caution with areas near the eye.
3. 
Procedure:
a. 
Use pressure to achieve hemostasis and clean the wound as explained previously.
b. 
Hold together wound edges.
c. 
Apply adhesive dropwise along the wound surface, avoiding applying adhesive to the inside of the wound. Hold in place for 20 to 30 seconds.
d. 
If the wound is misaligned, remove the adhesive with forceps and reapply.
e. 
Adhesive will slough off after 7 to 10 days.
VII
Musculoskeletal Procedures
A. 
Basic Splinting 3
1. 
Indications: to provide short-term stabilization of limb injuries
2. 
Complications: pressure sores, dermatitis, neurovascular impairment
3. 
Procedure:
a. 
Determine style of splint needed
b. 
Measure and cut fiberglass or plaster to appropriate length. If using plaster, upper-extremity splints require 8 to 10 layers, and lower-extremity splints require 12 to 14 layers.
c. 
Pad extremity with cotton Webril, taking care to overlap each turn by 50%. In prepackaged fiberglass splints, additional padding is not generally required. Bony prominences may require additional padding. Place cotton between digits if they are in a splint.
d. 
Immerse plaster slabs into room-temperature water until bubbling stops. Smooth out wet plaster slab, avoiding any wrinkles. 
Warning: Plaster becomes hot after drying.
e. 
Position splint over extremity and wrap externally with gauze. When dry, an elastic wrap can be added.
f. 
Alternatively, wet one side of fiberglass until saturated. Roll or fold to remove excess water. Mold splint as indicated. 
NOTE: Using warm water will decrease drying time. This may result in inadequate time to mold splint. Turn edge of the splint back on itself to produce a smooth surface. Take care to cover the sharp edges of fiberglass. When dry, wrap with elastic bandage.
g. 
Use crutches or slings as indicated.
h. 
The need for orthopedic referral should be individually assessed.
B. 
Long Arm Posterior Splint
1. 
Indications: Immobilization of elbow and forearm injuries
Long arm posterior splint.
C. 
Sugar Tong Forearm Splint
1. 
Indications: For distal radius and wrist fractures, to immobilize the elbow and minimize pronation and supination
D. 
Ulnar Gutter Splint
1. 
Indications: Nonrotated fourth or fifth (boxer) metacarpal metaphyseal fracture with less than 20 degrees of angulation, uncomplicated fourth and fifth phalangeal fracture.
2. 
Assess for malrotation, displacement (especially Salter I–type fracture), angulation, and joint stability before splinting.
3. 
Procedure: Elbow in neutral position, wrist in neutral position, metacarpophalangeal (MP) joint at 70 degrees, interphalangeal (IP) joint at 20 degrees. Apply splint in U shape from the tip of the fifth digit to 3 cm distal to the volar crease of the elbow. Splint should be wide enough to enclose the fourth and fifth digits.
E. 
Thumb Spica Splint
1. 
Indications: Nonrotated, nonangulated, nonarticular fractures of the thumb metacarpal or phalanx, ulnar collateral ligament injury (gamekeeper's or skier's thumb), scaphoid fracture or suspected scaphoid fracture (pain in anatomic snuff box).
2. 
Procedure: Wrist in slight dorsiflexion, thumb in some flexion and abduction, IP joint in slight flexion. Apply splint in U shape from tip of thumb to mid-forearm. Mold the splint along the long axis of the thumb so that thumb position is maintained. This will result in a spiral configuration along the forearm.
F:Volar Splint
1. 
Indications: Wrist immobilization.
2. 
Procedure: Wrist in slight dorsiflexion. Apply splint on palmar surface from the MP joint to 2 to 3 cm distal to the volar crease of the elbow. It is useful to curve the splint to allow the MP joint to rest at an 80- to 90-degree angle.
G. 
Posterior Ankle Splint
1. 
Indications: Immobilization of ankle sprains and fractures of the foot, ankle, and distal fibula.
2. 
Procedure: Measure leg for appropriate length of plaster. Splint should extend to base of toes and upper portion of the calf. A sugar tong (stirrup) splint can be added to increase stability for ankle fractures.

Radial Head Subluxation Reduction (Nursemaid's Elbow)
1. 
Presentation: Commonly occurs in children ages 1 to 4 years with a history of inability to use an arm after it was pulled. Child presents with affected arm held at the side in pronation, with elbow slightly flexed.
2. 
Caution: Rule out a fracture clinically before doing procedure. Consider radiograph if mechanism of injury or history is atypical.
3. 
Procedure:
a. 
Support the elbow with one hand, and place your thumb laterally over the radial head at the elbow. With your other hand, grasp the child's hand in a handshake position.
b. 
Quickly and deliberately supinate and externally rotate the forearm, and simultaneously flex the elbow. Alternatively, hyperpronation alone may be used. You may feel a click as reduction occurs.
c. 
Most children will begin to use the arm within 15 minutes, some immediately after reduction. If reduction occurs after a prolonged period of subluxation, it may take the child longer to recover use of the arm. In this case, the arm should be immobilized with a posterior splint.
d. 
If procedure is unsuccessful, consider obtaining a radiograph. Maneuver may be repeated if needed.
I. 



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