Pediatric Tips & Tricks

Ashley Strobel MD FACEPAssistant Professor of Emergency Medicine

Hennepin County Medical Center Emergency Department

University of MN Pediatric Emergency Medicine Division

@AStrobelMD #TwinCitiesPEMmetro #FOAMped

Objectives

• Understand family satisfaction in emergency care

• Discuss modalities to increase efficiency during common pediatric emergency encounters

• Increase your job satisfaction

• Enjoy being a kidhealer

NO DISCLOSURES

Kids keep us employed!

Neonate: 0-1 month

Infant/Toddler: 2 mth - 2 yo

School age: 5-8 yo Pre-puberty: 8-12 yo

0 1 2 3 4 5 6 7 8 9 10 11 12

Preschool: 3-5 yo

Weight Based Medications & Equipment: Avoiding Error

Age + 3.5 = ETT4

ETT x 2 = OG/NG/Foley FR

ETT x 3 = Depth ETT

ETT x 4 = Chest Tube FR

Laceration Repair

Intranasal Anxiolysis

Midazolam:

0.3-0.5 mg/kg

Fentanyl:

1-2 mcg/kg

Dexmedetomidine:

2-3 mcg/kg

Ketamine:

1-2 mg/kg

Distraction Aids

Laceration Repair Made

Easy!

• LET 20 min

• RN/Child Life procedural prep

Laceration Repair Made

Easy!

• LET 20 min

• RN/Child Life procedural prep

Laceration Repair

Bravery Deserves a Reward!

Nasal Foreign Body:

Mother’s Kiss

Nasal Foreign Bodies Made Easy

Nasal Foreign Body Adjuncts: N2O

Nasal Foreign Body “Treasures”

Kids are fun!

REPLACING A G-TUBE

RULE OF 50s!

10 x 5 = 50

Infant (<1 yo): D10NS 5 mL/kg

25 x 2 = 50

Child (1-8 yo or <50 kg):D25W 2 mL/kg

50 x 1 = 50

Pre-Teen (>8 yo or >50kg):D50W 1 mL/kg

References

• G-Tube Dislodgement

• http://pemcincinnati.com/blog/g-tube/

• Juern, Jeremy, and Amy Verhaalen. “Gastrostomy-Tube Exchange.” New England Journal of Medicine, vol. 370, no. 18, 2014, doi:10.1056/nejmvcm1207131.

• http://www.nationwidechildrens.org/feeding-tube-changing

• Saavedra, Heather, et al. “Gastrostomy Tube-Related Complaints in the Pediatric Emergency Department.” Pediatric Emergency Care, vol. 25, no. 11, 2009, pp. 728–732., doi:10.1097/pec. 0b013e3181bec847.

• Showalter, Cory D., et al. “Gastrostomy Tube Replacement in a Pediatric ED: Frequency of Complications and Impact of Confirmatory Imaging.” The American Journal of Emergency Medicine, vol. 30, no. 8, 2012, pp. 1501–1506., doi:10.1016/j.ajem.2011.12.014.

• Goldin, Adam B., et al. “Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement.” The Journal of Pediatrics, vol. 174, 2016, doi:10.1016/ j.jpeds.2016.03.032.

• Bhambani, Shiloni, et al. “Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department.” Western Journal of Emergency Medicine, vol. 18, no. 4, Jan. 2017, pp. 770–774., doi:10.5811/westjem.2017.3.31796.

• Laceration Repair

• ALiEM https://www.aliem.com/2009/06/tricks-of-trade-tissue-adhesives-and/

• Karounis H, GouinS, EismanH, Chalut D, Pelletier H, Williams B. A Randomized Controlled Trial Comparing Long-term Cosmetic Outcome of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versusNonabsorbableNylon Sutures. Acad Emerg Med. 2004; 11:730-735.

• Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T, Vandermeer B. Tissue adhesives for traumatic lacerations in children and adults (Review). Cochrane Database of Systematic Reviews. 2002; 3.

• Bougienage

• ACEP NOW May 2015 Terrance McGovern, DO, Justin Mcnamee, DO, Julie Sanicola-Johnson, DO

• Bonadio WA, Jona JZ, Glicklich M, Cohen R. Bougienage Technique for Coin Ingestion in Children. J Ped Surg. Oct 1988; 23: 917-918.

• Arms JL, Mackenberg-Mohn MD, Bowen MV, Chamberlain MC, Skrypek TM, Madhok M, Jimenez-Vega JM, Bonadio WA. Safety and Efficacy of a Protocol Using Bougienage or Endoscopy Management of Coins Acutely Lodged in the Esophagus: A Large Case Series. Ann Emerge Med. 2008;51: 367-372. (youngest age 9 months)

• Emslander RC, Bonadio WA, Klatzo M. Efficacy of Esophageal Bougienage by Emergency Physicians in Pediatric Coin Ingestion. Ann Emerg Med. June 1996; 27: 726-729. (safely performed by non-surgeon EM physicians)

• Aliie EH, Blackshaw AM, Losek JD, Tuuri RE. The Effectiveness of Bougienage for esophageal coins in a Pediatric ED. Amer J Emerg Med. 2014; 32: 1263-1269. (used intranasal midazolam. 4 children < 1 year old with the youngest 6 months of age using 24-28F Hurst dilators)

• Calkins CM, Christians KK, Sell LL. Cost Analysis in the Management of Esophageal Coins: Endoscopy vs Bougienage. J Ped Surg. 1999; 34: 412-414.

• Heinzerling NP, Christensen MA, Swedler R, Cassidy LD, Calkins CM, Sato TT. Safe and effective management of esophageal coins in children with bougienage. Surgery. 2015; 158: 1065-1072.

• Foreign Body Removal

G-tube Emergencies

• Hypoglycemia

• Stoma closure

G-Tube Emergencies• When was it placed?

• <3 months, call technician

• How was it placed?

• Peds Surg, GI, IR

• How long has it been out?

• Goal: replace within 2-4 hours

• What is the size of G-tube? (diameter FR and length)

Shout Out:Child Family Life

Hair Tourniquet

Foreign Body Removal

Pediatric Friendly

Care

Needle Cricothyrotomy

• Can’t Intubate, Can’t Ventilate

• Make the decision to save a life!

• <30 seconds

Esophageal Coin Ingestion: Management

Options

1. 30-50% of esophageal coins pass on their own

2. Foley Catheter

3. GI or Surgery consult for endoscopic removal

4. Bougienage

Inclusion Criteria for Esophageal Bougienage

1. Witnessed ingestion

2. Foreign body is a coin

3. Coin radiographically located in esophagus

4. Single coin present

5. Coin lodged fewer than 24 hours

6. No previous hx of esophageal

foreign body, disease process, or surgery

7. No respiratory compromise on physical exam

8. Trained personnel performing procedure

Tips for success!

Don’t show the bougie until the last minute!!

You only get 1 opportunity!!

Bite block

Benzocaine spray or lidocaine 4% nebulizer for preparation

Consider IN Midazolam, Nitrous nasal, or IN/IM Ketamine