Pediatric emergency medicine trisk 1089

Use local anesthesia in children—this includes placement of topical anesthetic cream 45 to 60 minutes prior to the LP if time allows Anesthetize the site by injecting 1% lidocaine intradermally to raise a wheal, then advance the needle into the desired interspace, injecting anesthetic and being careful not to inject into a blood vessel or the subdural space into the CSF Check the spinal needle and ensure the stylet is secure Grasp the spinal needle firmly with the bevel facing “up” toward the ceiling, making the bevel parallel to the direction of the fibers of the ligamentum flavum Recheck the patient’s position to ensure the needle’s trajectory is midsagittal to the patient’s back Insert the needle into the skin over the selected interspace in the midline sagittal plane Two methods of stabilizing and guiding the needle are shown ( Fig 130.11A , parts B and D) Insert the needle slowly, aiming slightly cephalad toward the umbilicus When the ligamentum flavum and then the dura are punctured, a “pop” and decreased resistance may be felt Remove the stylet and check for flow of spinal fluid If no fluid is obtained, advance the needle slowly, and check frequently for the appearance of CSF An alternative to keeping the stylet in during the procedure is early stylet removal after the needle has passed through the dermis Removing the stylet early reduces the likelihood of a traumatic tap Using a hollow needle or removing the stylet too early increases the risk of a small bit of epidermis entering the spinal needle and either blocking CSF drainage or being unintentionally introduced into the CSF space, where an epidermoid tumor may form When CSF flows, attach the manometer to flexible tubing (if available), and attach the flexible tubing to the needle’s hub if an opening pressure is to be measured Some kits allow the manometer to be attached directly to the hub of the spinal needle with a 3-way stopcock, rather than using flexible tubing Allow the CSF to travel up the manometer and reach a point where it stabilizes and varies slightly with respirations Gently relax the patient’s legs so as not to artificially elevate the pressure reading Collect mL of CSF in each of the three sterile tubes Send the CSF for routine culture, Gram stain, glucose and protein determination, and cell count and differential Collect additional tubes as indicated for specific testing After CSF collection is complete, a closing pressure can be measured in the same way as the opening pressure Reinsert the stylet and then remove the spinal needle Cleanse the back and cover the puncture site Observe the site for any evidence of ongoing CSF leak Sitting Position Restrain the patient in the seated position with maximal spinal flexion ( Fig 130.11A , part C) For infants, have the assistant hold the infant’s hands between his/her flexed legs with one hand and flex the head with the other hand Place drapes underneath the child’s buttocks and on the shoulders with an opening near the intended spinal puncture site Choose the interspace as noted earlier and follow the procedure as outlined for the lateral position Insert the needle so it runs parallel to the spinal cord ( Fig 130.11A , part D) Opening pressure should not be measured in this position, but in cooperative older patients or sedated patients, it is feasible to obtain entry in the sitting position and then pivot the patient carefully to the lateral decubitus position to measure opening pressure PNEUMATIC OTOSCOPIC EXAMINATION Indications Evaluation for presence of middle ear effusion Complications Pain or bleeding from contusion or abrasion of the external auditory canal Procedure To safely and accurately evaluate the middle ear structures in infants, minimizing patient movement while performing the examination is critical In many infants, this requires appropriate restraint Many young children fear the approach of a physician, particularly to examine their ears Usually a parent can provide proper immobilization Place the infant supine on the examination table, and ask a parent to hold the arms firmly against the trunk ( Fig 130.12A ) or against the head, grasping them just above the elbow When assisting, the parent may hold his/her hand across the forehead against his/her own chest to minimize movement Hold the otoscope as shown in Figure 130.12B , grasping it between the thumb and index finger of the dominant hand The heel of the hand should rest against the anterior portion of the infant’s head to maintain constant, firm pressure against the temporal skull while bringing the infant’s head horizontal to the table This assists the operator in ensuring the otoscope will move in conjunction with the child if he/she is not still during the procedure Once the infant is restrained, use the other hand to grasp the upper portion of the helix, stretching it superiorly and posteriorly in the child to straighten the external canal In young infants, pull the helix posteriorly to best visualize the tympanic membrane Simultaneously, observe the entrance to the auditory canal through the otoscope and flex the thumb to direct the speculum down the canal entrance Then, straightening of the external canal is performed under direct visualization The removal of cerumen obscuring the field may be necessary (see Procedure in Removal of a Foreign Body From the Ear section) Observe the tympanic membrane for color, contour, and presence of the bony and vascular landmarks (see the “Otitis Media” section in Chapter 58 Pain: Earache ) For evaluation of the compliance of the tympanic membrane, a tight seal is required between the auditory canal and the speculum If the diameter of the speculum is found to be less than that of the canal, replace it with one of a larger size Reenter the canal to one-third to one-half of its depth, establish a seal, and lightly squeeze the bulb while observing the tympanic membrane In the presence of an adequate seal, lack of movement of the tympanic membrane indicates the presence of a middle ear effusion FIGURE 130.12 Pneumatic otoscopic examination REMOVAL OF A FOREIGN BODY FROM THE EAR Indications Foreign body Obstruction of the external auditory canal by cerumen Complications Abrasion of the external auditory canal Perforation of the tympanic membrane Ossicular disruption Procedure Multiple methods are available for removal of a foreign body from the external auditory canal; all require cooperation from, or restraint of, the child Pharmacologic sedation may facilitate safe performance of the procedure, but extreme caution must be exercised in a sedated patient in order to avoid damage to structures of the middle ear Objects lying on or near the tympanic membrane should be referred to an otolaryngologist Inorganic materials, with the notable exception of button batteries, may not require emergent removal and can be referred for elective removal Whenever possible, foreign bodies should be removed under direct visualization in order to avoid complications Minor abrasion and laceration of the external auditory canal is often unavoidable during the procedure, and parents should be made aware of this complication before beginning the procedure After removal of the foreign body or cerumen by any method, it is important to visualize the tympanic membrane and document its condition Curette Visualize the foreign body with a speculum, preferably using an operating head otoscope or metal ear speculum ( Fig 130.13A ) Then, slowly advance the curette just beyond the foreign body as shown While applying pressure to the foreign body, slowly withdraw the curette until the foreign body is removed Space to pass the tip of the curette beyond the foreign body is a prerequisite for success with this method Forceps Visualize the foreign body with a speculum, preferably using an operating head otoscope or metal ear speculum, and look for a protruding edge of the foreign material ( Fig 130.13B ) Carefully guide the forceps in the closed position under direct visualization through the speculum Just a few millimeters from the edge of the foreign body, open the forceps and grasp the edge gently Withdraw the forceps while maintaining visualization of the foreign body and the external auditory canal to minimize the chance of a complication Irrigation