Pediatric emergency medicine trisk 1088

the thumb and forefinger of the nondominant hand Insert the Huber needle slowly through the skin directly into the septum of the circular reservoir until the back of the reservoir is reached Unclamp and gently withdraw to assess for the presence of blood, then slowly inject saline Watch for local infiltration, which may occur if the needle is not properly placed If local infiltration occurs, remove the Huber needle Blood drawing is accomplished through extension tubing after clearing the line of dead space volume If blood is being drawn, to mL must be drawn and discarded before collecting the amount necessary for testing Place a dressing over the site and secure the catheter with chevron-shaped silk tape Medications or intravenous fluids may be attached Normal saline flushes should be administered between medications Flush with mL of heparinized solution when medication or fluid administration is complete or after blood drawing is accomplished Remove the Huber needle Place a dressing or adhesive bandage over the site once the needle has been removed Peripherally Inserted Central Catheters To access a PICC, first scrub the access port per institutional protocol, using a twisting, frictional scrub for a minimum of 15 seconds and then allow for complete drying Using sterile technique, access the port of the lumen with a 10mL syringe filled with normal saline Aspirate to confirm blood return After confirming patency, flush using a pulsatile technique until all flush solution has been administered, thus clearing the line of blood, medication, and/or intravenous fluid Maintain pressure at the end of the flush to prevent the reflux of blood into the catheter; repeat for each lumen of the catheter Follow the manufacturer’s instructions for the clamping procedure at the end of the flush Nonpatent Catheters—Use of Fibrinolytics When tunneled CVCs or implantable ports are not readily accessed, the most common reason is presence of a clot The clinician should consider use of a fibrinolytic to assist in clot dissolution as long as it is not contraindicated Alteplase (2 mg/2 mL) For patients weighing less than 30 kg, alteplase can be instilled in an amount equal to the catheter priming volume plus 10%, not to exceed mL (2 mg) and should be allowed to dwell within the catheter lumen for 120 minutes For patients weighing more than 30 kg, a 2-mg dose should be instilled and allowed to dwell within the catheter lumen for 120 minutes Then, attempt to withdraw blood with a 5- to 10-mL syringe For more complex problems, including intraluminal mineral/precipitant occlusion or lipid emulsion occlusion, refer to the staff caring for the catheter LUMBAR PUNCTURE Indications To obtain cerebrospinal fluid (CSF) for the diagnosis of meningitis, meningoencephalitis, subarachnoid hemorrhage, and other neurologic syndromes To measure opening pressure to diagnose idiopathic intracranial hypertension Complications Contamination of the CSF sample with blood from the epidural venous plexus Local back pain—occasionally with short-lived referred limp Headache (uncommon in children younger than 10 years of age) Apnea/hypoventilation caused by positioning for the procedure in young infants Spinal epidural/subdural hematoma or spinal cord bleeding—especially in the presence of bleeding diathesis Infection Subarachnoid epidermoid tumor formation Ocular muscle palsy (transient) Epidural CSF leak—ranging from asymptomatic to cauda equina syndrome 10 Brainstem herniation—in the presence of a mass effect or noncommunicating hydrocephalus Equipment Commercial trays; CSF manometers; spinal needle—22 gauge; 3.75 cm (1.5 in) for younger than year old, 6.25 cm (2.5 in) for year to middle childhood, and 8.75 cm (3.5 in) for older children and adolescents; povidone-iodine or chlorhexidine antiseptic solution; topical 4% lidocaine cream Procedure Lateral Decubitus Position Restrain the patient in the lateral decubitus position Maximally flex the spine without compromising the upper airway Often, in infants younger than months, the patient’s hands can be held down between the flexed knees with one of the assistant’s hands The other hand can flex the neck at the appropriate time The spinal cord ends at approximately the level of the L1 and L2 vertebral bodies Caudal to L2, only the filum terminale is present The desired sites for LP are the interspaces between the posterior elements of L3 and L4 or L4 and L5 Locate these spaces by palpating the iliac crest ( Fig 130.11A , parts A and D) Follow an imaginary “plumb line” from the iliac crest to the spine The interspace encountered is L4–L5 Use it or the one cephalad to it Employ sterile technique for the LP Cleanse the skin with antiseptic solution after donning sterile gloves Using sponges, begin at the intended puncture site and work outward in concentric circles until an area 10 cm in diameter has been cleansed Repeat this three times Drape the child beneath his/her flank and over the back with the spine accessible to view (as in Fig 130.11B ) Allow the solution to dry An alternative to draping the patient, which may obscure key anatomic landmarks, is to cleanse the skin with antiseptic solution all the way onto the iliac crests to create a sterile field that can be palpated again at any time during the procedure without compromising the sterile field FIGURE 130.11 Lumbar puncture