increased coping ability in children In addition, caregivers want to be present and report less anxiety when in attendance for invasive procedures Restraint by Personnel Various methods can be used to restrain children for simple emergency procedures as listed above Often, a single assistant can minimize movement of a child The specific positioning for procedures is illustrated with individual procedures The assistant’s hold must be firm enough to prevent movement that would make the procedure more difficult to perform or more likely to induce complications Though uncommon, the use of excessive force may cause superficial or more serious injury With thorough assessment by the care team, careful preparation and attention to distraction, procedures can be very successful with minimal restraint in a cooperative child Bundling Wrap This is an alternative gentle restraint for use during emergency procedures With this, the practitioner can easily access the head as well as upper and lower extremities This method can help infants feel secure and can keep younger toddlers less mobile Leaving one arm/hand out of the wrap for a parent to hold can make the wrap feel less restrictive as well as increase comfort through parental contact and give the patient an opportunity to hold or touch a distraction item Older children will generally not tolerate this wrap very well and other methods should be considered In some settings, using the bundling wrap inside of a papoose (see below) is an acceptable alternative An injured extremity can be left out of the wrap for better exposure Fold a bedsheet on itself so that the width measures from the axillae to the heel of the child Stand the child on the bed and place the bedsheet behind his/her back, under the axilla, and in front of the arms as in Figure 130.1A , with the short end of the sheet tucked behind one arm around the child’s back With the child standing, wrap the long end of the sheet on the child’s other side, around the back to the front and across the trunk again, finishing behind the child, as in Figure 130.1B Lay the child supine or prone to best expose the injury to be treated Papoose Figure 130.1C depicts an example of a papoose, which can be used as a last resort for restraint during repair of lacerations and other wounds It is generally used to expose the head, face, and extremities to maximize efficiency With increased child life presence and staff support and education, many centers have significantly reduced their use of this tool After explaining the procedure to the family, open the papoose across the ED stretcher Place the child supine on the papoose, and expose the body area necessary for treatment Beginning with the midabdominal restraints, cover the child across the midline with the Velcro-lined flaps ( Fig 130.1C ) Better exposure of the extremities, such as the hand, is obtained by flexion of the area under the harness ( Fig 130.1D ) Before starting a wound repair or other procedure, reassess for the safety and adequacy of immobilization of the child and correct it if necessary Again, leaving an arm/hand free for a parent or staff member to hold can aid in both comfort and distraction There is a small group of children with autism spectrum disorders (ASDs) that may find the papoose calming due to the containment and pressure The papoose may be offered to families with children with an ASD as a first line of restraint as opposed to manual restraint by staff EXTERNAL JUGULAR VENIPUNCTURE OR PERIPHERAL CANNULATION Indications Venous blood sampling or placement of a peripheral intravenous catheter when peripheral veins on the extremities are inadequate Complications Hematoma Infection Equipment Venous blood sampling: Butterfly (21 to 23 gauge); 5- to 10-mL syringe; povidone-iodine or chlorhexidine antiseptic solution; sterile gauze FIGURE 130.1 A, B Application of papoose C, D, E Application of bundling wrap Peripheral intravenous cannulation: over-the-needle catheter, 20 or 22 gauge; povidone-iodine or chlorhexidine antiseptic solution, tape or other securement device Ultrasound can be used to guide the procedure (see Chapter 131 Ultrasound ) Procedure If time allows, apply topical or local anesthetic over the expected puncture site to achieve local anesthesia of the superficial skin Place the patient on the examining table in the supine position with the patient’s shoulders to 10 cm from the end of the table Have the assistant lean over the patient to stabilize the trunk The assistant then holds the shoulder ipsilateral to the external jugular vein to be punctured with one hand and places the other hand over the ipsilateral zygoma and forehead, turning the head toward the contralateral shoulder and dropping the head 15 to 20 degrees over the table top Alternatively, the bed can be placed in the Trendelenburg position with the head down 15 to 20 degrees Attach the butterfly to the syringe and check for patency if venipuncture for blood draw is to be performed Cleanse the skin over the vein circumferentially with the antiseptic solution Allow the antiseptic solution to dry If the vein is not easily visualized in this position, it may be necessary to stimulate an infant to cry or a cooperative patient to perform a Valsalva maneuver to improve filling and visualization of the vein Slight manual pressure may also be applied parallel to the superior margin of the clavicle by placing a finger along the clavicular border to promote venous filling and improved visualization Align the butterfly needle (for venipuncture) or the over-the-needle catheter (for venous cannulation) parallel to the vessel as shown in Figure 130.2 , and pierce the skin near the white circle shown overlying or just next to the vein approximately one-half to two-thirds of the distance between the angle of the jaw and the clavicle Then with gentle suction applied if using the syringe, advance the needle ( Fig 130.2 , dotted line ) or over-the-needle catheter until the external jugular vein is entered If performing venipuncture, relieve the suction on the syringe and withdraw the needle after withdrawing an adequate blood sample, and apply a sterile gauze dressing The assistant should bring the infant to the upright position and compress the venipuncture site for minutes If performing venous cannulation, advance the catheter into the vein, and remove the needle Secure the catheter with tape or other securement device RADIAL ARTERY PUNCTURE OR CANNULATION Indications