So what just rolled in the door, leaving a trail of blood behind? A 26 year old with a stellate laceration to the face after a night of drinking? No problem, he won't even need local anesthesia. A construction worker with a deep laceration down to his forearm muscle bellies? Might take up a big chunk of time, but no big deal, we can throw in a handful of horizontal mattresses.
What's that now? A 0.5 cm forehead laceration? What's the issue? Why are you so....oh good god...it's....it's....IT'S A TWO YEAR OLD!!?!??!?!
These seemingly trivial lacerations, often small and on the upper face, invoke true fear and loathing in the largely adult trained EP. We have to sew on a field that's moving and screaming? For god's sake man, I'm a doctor, not a...
Our friends in the PEM world fortunately have left us with a few hacks to make our lives significantly easier with these kiddos. So let's stand up to our demons and learn a thing or two!
Before we do anything, let's get this little fella comfortable. Slap on some of that LET we've heard so much about! Wait, does this stuff actually do anything?
An RCT from the Canadian Medical Association Journal in 2013 (n=221) showed that these kids did in fact have less pain with the procedure, and were more likely as compared to placebo (51.6% vs. 28.3%) to have a completely pain-free procedure. In short it often precludes the need for any local anesthesia (because it turns out that kids do not like needles). It also was shown to increase hemostasis. So slather that stuff on, but make sure you wait long enough for it to take effect (about 15-20 min).
Do you papoose? We sure like to! It is safer for the child in general, as well as it is for us. I've had a kid actually ask me to put him in there before--maybe it made him feel more secure?
From here on out, distraction is essential. Again, the data supports that things like music, video games, and cartoons can take the child's mind off what you're doing, and help them relax. It'll also take the stress away from what is likely an extremely anxious parent as well. There's a cool iPhone app called "Eye Handbook" that has tons of cartoon animations that kids can fixate on, so you always have something in your pocket.
Irrigation can also be alarming to the child, but you can employ a cool Macgyver maneuver thanks to the ingenious Dr. Michelle Lin. Essentially you can take a collection bin and cut out a rectangular or semi-circular hold from the edge, leaving enough of a lip so that water doesn't trickle out. You'll want it to look like a hair salon basin.
Anxiolysis isn't required but it can definitely be your friend. A very popular option is intranasal midazolam, with the dose being between 0.2-0.3 mg/kg. Your max dose will be 5 mg. This plus Thomas the Train on dad's iPad will put your little guy or girl in a zen-like state of serenity.
Some data has shown that intranasal ketamine (up to 9 mg/kg, go big or home!) can have a high success rate without the use of an IV. However, you're getting into the realm of sedation at this point, not just anxiolysis. My PEM sources are also not a big fan of this one either, so make sure you really do your research and have the appropriate setup (i.e. pulse ox, end tidal CO2, an extra nurse, etc.) if you're going to undergo this.
In terms of the actual repair, it really just helps to keep it simple. Simple interrupted! You may opt to use the absorbables for superficial closure if the wound is small, and you think removing sutures will be a major headache for the kiddo. Deeper lacs should always make you think of repairing deeper levels with absorbables as the frontalis muscle may be affected. Just remember that you do need to work faster than you're used to with adults, so make sure you get it right on the first try.
Adhesives like cyanoacrylates can also come in handy in a pinch but you need to ensure that nothing drips down into the eyes of your flailing kiddo if the laceration is on the forehead or eyebrow. You can get around this by placing a little ridge of petroleum jelly inferior to the wound as a barrier. You can also place them in Trendelenberg to limit the amount of drippage. If it does get in the eye, DON'T USE WATER TO IRRIGATE! This might cause the polymerization to accelerate, so you'll actually want to use topical antibiotics like erythromycin (remember, it causes it to break down) instead. And call an ophthalmologist.
As always, these posts are made for EDUCATIONAL PURPOSES ONLY. Treat each of these children as if they were one of your own!
jps
Sources:
Harman, S., Zemek, R., Duncan, M. J., Ying, Y., & Petrcich, W. (2013). Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 185(13), E629–34. doi:10.1503/cmaj.130269
Academic Life in Emergency Medicine - "Trick of the Trade: Pediatric Distractors" http://www.aliem.com/trick-of-the-trade-pediatric-distractors/
Sinha, M. (2006). Evaluation of Nonpharmacologic Methods of Pain and Anxiety Management for Laceration Repair in the Pediatric Emergency Department. Pediatrics, 117(4), 1162–1168. doi:10.1542/peds.2005-1100
Tsze, D. S., Steele, D. W., Machan, J. T., Akhlaghi, F., & Linakis, J. G. (2012). Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatric Emergency Care, 28(8), 767–770. doi:10.1097/PEC.0b013e3182624935
