After a shift, we often review the day’s case with our learners. We sometimes ask them to self-reflect.
I often used Demian’s ‘Plus/Delta’ approach and ask ‘What did you like /what would you change?’
This approach works well mostly. But, when the answer is ‘I don’t think I would change anything’, it is hard to target teaching and feedback to the learner’s need.
What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED?
A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it.
You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?
Lacerations of the finger can bleed quite profusely because of digital vascularity. This obscures the provider’s ability to perform a careful exam and can make suturing quite difficult. Simple direct pressure over the laceration often controls the bleeding.
What if this doesn’t work?
Ingrown toenails, or paronychias, are usually exquisitely painful and a bit gnarly when they present to you in the Emergency Department. Dr. Stella Yiu described toenail splinting techniques using steristrips or dental floss. The purpose of splinting is to prevent the toenail from growing back into the lateral nail fold.
This assumes a relatively mild-to-moderate case. Often simple elevation of the nail out of the lateral nail fold (under digital block anesthesia) is all that is needed to treat a paronychia. Pus is often released with this maneuver.
There’s no toenail to slide the steristrip/ cotton/ dental floss material under.
Emergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots
Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer.
There are many ways to relocate a shoulder dislocation. Most of these ways require procedural sedation. What if the risks of procedural sedation outweigh the risks? What alternative maneuver can you try, which only requires parenteral pain medications +/- an intra-articular lidocaine?
Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control.
Intranasal (IN) fentanyl
Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:
It is imperative that the drug be administered in a nebulized form using an atomizer device — one half the volume in each nostril. Attach a 1 cc syringe to the end of the atomizer to administer fentanyl intranasally.
It is rapidly absorbed and provides excellent analgesia within minutes. It works just as well as IV morphine (1). If you just drop the liquid in the nose without using the atomizer, the child will swallow some of the drug, and onset and effect will be blunted significantly and titration is not possible.
The starting dose of 1.5 microgram/kg can be repeated in a dose of 0.5-1.5 microgram/kg IN in 5 minutes. Be sure to use extreme caution in younger patients who are more susceptible to the respiratory depressant effects of all opiates; it has not been tested in children < 3 years of age at all, so I would not use in this age group. Put patients on a pulse oximeter. In the event that a child receives the drug and starts to desaturate, bag the patient, then just give naloxone 0.1 mg/kg/dose to a maximum of 2 mg intramuscularly, and the respiratory effects will be rapidly reversed.
Reference
1. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40.