2 Ankylosis of reimplanted tooth to the surrounding bone Root resorption Tooth discoloration Equipment Tooth preserving liquid medium (ViaSpan, Hank’s balanced salt solution, milk) Tongue depressors Light source Saline solution Sterile gloves and gauze Suction and suction catheter Procedure An avulsed tooth has a 90% survival rate when it is reimplanted within 30 minutes A successful reimplantation requires maintaining viability of the periodontal ligament fibers which secure the root to the alveolar bone After an avulsion occurs, these fibers are present on both the alveolar bone and the root, so the avulsed tooth should only be handled by the crown These fibers also not tolerate being dry so if the tooth cannot be immediately reimplanted, it should be placed in an appropriate liquid medium Examples of preferred solutions are ViaSpan and Hank’s balanced salt solution If these are not readily available, cool milk is the next best option, followed by intraoral saliva then saline solution A last resort option is water, which is better than letting the root dry out Unpreserved teeth reimplanted after 60 minutes rarely survive Consider administering analgesia prior to the procedure as long as it does not significantly delay the procedure However, local anesthetic or sedation is usually not necessary Prior to reinsertion, the tooth should be gently swirled in appropriate medium or irrigated with saline Never scrub the tooth Locate the empty socket If multiple teeth require reimplantation, ensure each tooth is matched with its original socket Lightly suction or use gauze to swab the surrounding area to optimize visualization Flush the socket with saline to evacuate any clot Position the tooth at the socket and reinsert it using firm, gentle pressure The tooth will protrude more than the non-avulsed teeth Hold the tooth in place or have the patient bite down on gauze until the dentist arrives ( Fig 130.22 ) Emergent dental consultation is mandatory to immediately splint the tooth to adjacent teeth Consider initiating a 7-day course of prophylactic penicillin and administering a tetanus booster if clinically indicated Discharge instructions should include a soft diet, regular brushing with a soft toothbrush, analgesia, chlorhexidine mouth rinse, and dental follow up in to 10 days for splint removal In older children, root canal therapy is usually necessary to minimize root resorption FIGURE 130.22 Reinserting an avulsed tooth Cleansing the avulsed tooth (A ), Clearing blood and secretions from the surrounding area (B ), Reimplanting the tooth (C ), Stabilizing the reimplanted tooth (D ) (Reprinted with permission from King C, Henretig FM, King BR, et al Textbook of Pediatric Emergency Procedures 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008.) REPLACEMENT OF A TRACHEOSTOMY CANNULA Indications Relief of obstruction of a tracheostomy tube (i.e., secretions, mucous plug, or foreign body) Accidental decannulation Complications Respiratory distress or failure Creation of a false tracheal passage with resultant pneumomediastinum and pneumothorax Procedure Replacement of an Obstructed Tracheostomy Cannula The child with a tracheostomy who acutely develops tachypnea, cyanosis, decreased breath sounds, or severe retractions should be assumed to have a mechanical obstruction of his/her cannula until proven otherwise Obtain scissors, a new cannula (often available from the parents), or an endotracheal tube of the same external diameter or one size smaller than the obstructed tube Ventilate the child with 100% oxygen Place a small, folded towel under the child’s shoulder, and extend the head and neck This maneuver exposes the tracheostomy site and eliminates redundancy and flaccidity of the tissues which lie between the trachea and the anterior surface of the neck The trachea is thereby forced closer to the plane of the skin An attempt should be made to pass a suction catheter If the catheter passes, apply suction at 80 to 120 cm of water and withdraw over to seconds Immediately reventilate with 100% oxygen If the suction catheter will not pass through the tracheal cannula, the cannula must be changed immediately Consider deflating the balloon and administering oxygen via facemask Carefully cut the strings that secure the cannula Remove the tube, observe the tract of the tracheocutaneous fistula, and introduce the new cannula, preferably with internal obturator in place so the tip follows the course of the tracheocutaneous fistula ( Fig 130.23A ) Press the flanges of the tracheostomy tube against the child’s neck, and attach a resuscitation bag to the system Remove the obturator, ventilate the child, and check for symmetric breath sounds by auscultation, and check endtidal CO2 to confirm proper placement Insert a hemostat through a flange hole on the lateral aspect of the cannula and pull the tracheostomy twill (cloth tape) through so two equal lengths of twill are left that are long enough to go around the posterior aspect of the neck to knot through the opposite flange hole Before securing the knot, apply adhesive-backed foam, if available, to the string crossing the back of the neck With the neck flexed, tie the twill snugly If the cannula is properly secured, an index finger should fit snugly under the strings while the head is flexed Obtain a chest radiograph to ensure proper placement and to assess for pulmonary parenchymal change If a tracheostomy cannula is not immediately available, a standard endotracheal tube of the same external diameter can be used instead Care must be taken not to advance this longer tube beyond the carina by measuring it against the tracheostomy tube that is removed to estimate the appropriate distance for insertion The chest should be auscultated for equal breath sounds bilaterally, and position of the distal tip should be confirmed by a chest radiograph This is a temporizing measure, and the correct size tracheostomy cannula should be obtained and reinserted as soon as possible Replacement of a Dislodged Cannula When a tracheostomy cannula is dislodged from the stoma of a child that is completely tracheostomy-dependent, it must be replaced immediately Time may not allow for acquiring a clean tube Cut the strings and replace the dislodged cannula Hold it firmly in place until it can be secured or until a clean cannula is made available Occasionally, the tracheocutaneous stomal tract will constrict so the cannula cannot be replaced Several options are then available First, place a smaller tracheostomy cannula or endotracheal tube to allow oxygenation and ventilation Alternatively, as in Figure 130.23B , pass a smaller oxygen catheter (10Fr or 14Fr) If the child is cyanotic, connect the catheter to an oxygen source and provide oxygen at a minimal flow rate of L/minute (2 to L/minute if older than years of age) If the child is not cyanotic, move directly toward passing a tracheostomy cannula over the oxygen catheter into the stoma (Seldinger technique) The oxygen catheter will serve as a stylet to keep the tracheostomy cannula from being forced into a false passage If the cannula cannot be advanced, it may be necessary to oxygenate and ventilate the child with bag mask ventilation through the upper airway while an assistant covers the stoma with a gloved finger If the upper airway is obstructed, place a small, cuffed endotracheal tube (size 3.5 to 4.5) through the stoma, inflate the cuff, hold it in place, and use it to oxygenate the patient Efforts to place a more appropriate size airway can then be reasonably made Important Note Remember that acute cardiopulmonary failure or respiratory distress often means obstruction of the tracheostomy First, if unable to ventilate or suction, remove Second, try to cannulate Third, remember in some patients, an endotracheal tube can be passed through the mouth or tracheostomy stoma Last, remember to try the other procedures (e.g., oxygen catheter) NEEDLE THORACOSTOMY Indications Evacuation of a tension pneumothorax ... tooth (D ) (Reprinted with permission from King C, Henretig FM, King BR, et al Textbook of Pediatric Emergency Procedures 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008.) REPLACEMENT