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Lacerations
- 1. Comfort in pediatric minor procedures Pain free laceration repair for Esteban and Elsa EVELYNE D. TROTTIER, MD FRCPC PEDIATRIC EMERGENCY, CHU STE JUSTINE REVIEW BY: DR JOCELYN GRAVEL, MD, MSC, FRCPC, CHU STE JUSTINE, QC DR MATTHIEU VINCENT, MD FRCPC, HÔPITAL CHARLES-LEMOYNE, QC DR SIM GREWAL, MD FRCPC, BC CHILDREN’S HOSPITAL, BC DR SAMINA ALI, MD FRCPC, STOLLERY CHILDREN’S HOSPITAL, AB NO CONFLICTMarch 2016 www.urgencehsj.ca www.urgencehsj.ca
- 2. Objectives Laceration repair in the ED Importance of non pharmacologic intervention Importance of topical anesthetics Effectiveness of tissue adhesives Indication for absorbable sutures Indication for procedural sedation and analgesia
- 3. Case 1: Esteban, 2 yo, meets the coffee table corner… www.mja.com.au
- 4. Esteban’s facial laceration: Evaluation Exclude other injuries Exclude foreign body Confirm adequate immunization Baseline interventions: ‘‘The Essentials’’ Distraction + Positioning Topical anesthetics Glue/skin adhesives Generally, no sedation for simple laceration Young MJA 2005 www.rch.org.au/clinicalguide: Lacerations www.childrensmn.org/services/care-specialities-deparments/pain-program/childrens-comfort-promise/
- 6. Fein Pediatrics 2012 Sinha Pediatrics 2006 Young MJA 2005 Ha Int J Nurs Pract 2013 www.urgencehsj.ca Gain their trust! n’s Laceration: ssentials Keep child in contact with his/her parent Be flexible and creative Preparation: Explain in a manner appropriate for the child’s age Be at their eye level Do not lie: ‘‘It’s not going to hurt…’’ Avoid the term ‘‘pain’’ Use distraction Childlife specialist, if available
- 7. Esteban’s facial laceration: Topical Anesthetics-LET gel LET Gel: Lidocaine 4% Epinephrine 0.1% Tetracaine 0.5% From triage (AAP recommendation) Application: 30 min in wound LET Gel superior to LET liquid Dose AAP 3mL if >17kg, 0.175 mL/kg if < 17 kg Sherman PEC 2014 Harman CMAJ 2013 Fein Pediatrics 2012 Nicks IJEM 2010 Godin Md Qc 2006 www.rch.org.au: laceration www.urgencehsj.ca
- 8. Indications: Laceration < 5cm Laceration will require sutures Reduces discomfort while cleaning the wound Helps to achieve wound hemostasis prior to glue Sherman PEC 2014 Harman CMAJ 2013 Fein Pediatrics 2012 Nicks IJEM 2010 Godin Md Qc 2006 www.urgencehsj.ca Esteban’s facial laceration: Topical Anesthetics-LET gel
- 9. Contraindications: ≤ 3 months Allergy Laceration is on a mucosal surface Large wound Contaminated wound Precaution on extremities such as nose or ears High BP, peripheral vascular disease Sherman PEC 2014 Harman CMAJ 2013 Fein Pediatrics 2012 Nicks IJEM 2010 Godin Md Qc 2006 White PEC 2004 www.urgencehsj.ca Esteban’s facial laceration: Topical Anesthetics-LET gel
- 10. Glue (-cyanoacrylate) Excellent esthetic outcome Similar to sutures Farion Cochrane 2009 (Review of 2002) Singer AJEM 2008 Beam, JAT 2008 Godin Md Qc 2006 Young MJA 2005 www.rch.org.au/clinicalguide Esteban’s facial laceration: Glue/tissue adhesives
- 11. Esteban’s facial laceration: Glue/tissue adhesives Small increased rate of dehiscence ↑ strength with steristrips and benjoin For patients: Less discomfort, no removal needed For Clinician: Easy to use, faster, no needle Apply on dried wound edges brought together Avoid glue in the wound= act as a foreign body Singer AJEM 2008 Farion Cochrane 2009 (Review of 2002) Singer AJEM 2008 Beam, JAT 2008 Godin Md Qc 2006 Young MJA 2005 www.rch.org.au/clinicalguide
- 12. Indications ≤ 5 cm Clean Straight, low tension Hemostasis achieved Extreme care if around the eyes Farion Cochrane 2009 Singer AJEM 2008 Beam, JAT 2008 Godin Md Qc 2006 Young MJA 2005 www.rch.org.au/clinicalguide Esteban’s facial laceration: Glue/tissue adhesives
- 13. Contraindications Allergy Mucosal surfaces Contaminated wound, infected, bites or delay in closure Tension, articulation Active bleeding Singer AJEM 2008 Beam, JAT 2008 Young MJA 2005 www.rch.org.au/clinicalguide Esteban’s facial laceration: Glue/tissue adhesives
- 14. Esteban, ready to go www.mja.com.au
- 15. Case 2: Elsa, 4 yo, meets the door corner… www.studyblue.com
- 16. Elsa’s deep laceration: Evaluation Exclude others injuries Exclude foreign body Confirm adequate immunization Baseline interventions: ‘‘The Essentials’’ Distraction + Positioning Topical anesthetics Absorbable sutures Might require procedural sedation and analgesia Young MJA 2005 www.rch.org.au/clinicalguide: Lacerations www.childrensmn.org/services/care-specialities-deparments/pain-program/childrens-comfort-promise/
- 17. Fein Pediatrics 2012 Young MJA 2005 Elsa’s deep laceration: The Essentials For sutures… Keep child in contact with his/her parent Preparation Distraction, Childlife specialist Systemic analgesic Simple analgesics Opiate ± PSA may be require: Eg Nitrous, IN Fenta/midaz Gain their trust!
- 18. Elsa’s deep laceration: Local anesthetic- LET, lidocaine 1% LET gel Often is enough to reach adequate analgesia for suturing Lidocaine 1% ± adrenaline, infiltrated in wound Indications Complement to LET gel As first line if urgent repair required Fein Pediatrics 2012 Nicks IJEM 2010 Cepeda Cochrane 2010 Godin Md Qc 2006 www.urgencehsj.ca
- 19. Elsa’s deep laceration: Local anesthetic- LET, lidocaine 1% Lidocaine 1% ± adrenaline, infiltrated in wound Contraindications Allergy Maximal doses With adrenaline: 7mg/kg (lidocaine 1%: 10mg/mL then 0.7 mL/kg max) Without adrenaline: 4.5mg/kg (lidocaine 1%: 10mg/mL then 0.5mL/kg max) Fein Pediatrics 2012 Nicks IJEM 2010 Cepeda Cochrane 2010 Godin Md Qc 2006 www.urgencehsj.ca
- 20. Lidocaine 1%- Pain at injection reduced if: After LET gel (or EMLA) Addition of bicarbonate (v. important if lido w adrenaline = very acidic) Add bic 8.4% to lidocaine 1% ± adrenaline with a 1:10 proportion Withdraw 1mL of bicarbonate 8.4%, add 10mL of lidocaine 1% ± adrenaline for a total of 11mL solution Warm solution to body temperature (rub vial between hands) Slow injection Needle 27-30 g Within the wound Elsa’s deep laceration: Local anesthetic- LET, lidocaine 1% Fein Pediatrics 2012 Frank Can J Plas Surg 2012 Hogan An Emerg med 2011 Nicks IJEM 2010 Cepeda Cochrane 2010 Godin Md Qc 2006 www.urgencehsj.ca
- 21. Absorbable Sutures Indications Always prioritize absorbable sutures in pediatric patients Be careful if Articulations Under tension Luck PEC 2008 and 2013 Al Abdullah PEC 2007 Godin Md Qc 2006 Karounis Acad Emerg Md 2004 www.urgencehsj.ca Elsa’s deep laceration: Suturing
- 22. Elsa, Vers un nouveau départ www.pinterest.com
- 23. www.urgencehsj.ca www.urgencehsj.ca BASELINE INTERVENTIONS: THE ESSENTIALS -KEEP CHILD IN CONTACT WITH PARENT -PREPARATION AND DISTRACTION -LET GEL FROM TRIAGE -GLUE! -IF IMPOSSIBLE: -ABSORBABLE SUTURES ±LIDOCAINE 1% WITH BICARBONATE ±SYSTEMIC ANALGESICS ±PSA Comfort in pediatric minor procedures Pain free laceration repair for Esteban and Elsa
Editor's Notes
- Sherman PEC 2014: Simple educational initiatives can improve the use of topical anesthetics. (used educational session and triage poster) Harmann 2013: 3mL LET or placebo in <3cm wounds appropriate for tissue adhesive for all patients older than 3 months Fein Pediatrics 2012: From AAP-Relief of Pain and Anxiety in Ped Patients in Emergency Medical Systems: Protocols should be developed for topical anesthetic placement for laceration repair at triage. Laceration repair should be completed with an emphasis on minimizing pain and anxiety Uptodate 2011: 1-3mL 20-30 min Godin Md Qc 2006: Recette Gel LET (pharmacie CHUL)
- Sherman PEC 2014 LET gel offers many advantages for repair of tissue laceration including …vasoconstricion, promotion of dry surfaces required for tissue adhesive laceration repair and reduction of discomfort Harman CMAJ 2013 Treating minor lacerations (< 3cm) with LET before wound closure with tissue adhesive reduced ratings of pain and increased the proportion of pain-free repairs among children aged 3m-17yo . Complete hemostasis of the wound was also more common. Uptodate 2011 suggest less than 5cm for standing order EMLA pourrait aussi être utiliser pendant1h dans une lacération (Fein Pediatrics 2012, Godin Md Qc 2006, Young MJA 2005)
- Sherman PEC 2014: LET should not be applied to body parts where vasoconstriction in contraindicated: Finger tips, penis, tip of nose, lips, pinna of ears Harman CMAJ 2013: Children aged 3m to 17y . Excluded …wounds on the ear, fingers, toes Fein Pediatrics 2012: Allergy, gross contamination of wound Uptodate 2011: should not be applied… digits, penis, nose and ears… allergy… large wound… caution on mucous membrane… (contaminated also cited) Nicks IJEM 2010: avoiding mucosal membranes and large open wounds Godin 2006: pas utilisé sur les extrémités distales comme le bout des doigts, lobes oreille, ni sur les muqueuses
- Godin Md Qc 2006: Cyanoacrylate: Octyl cyanoacrylate (dermabond), Butyl cyanoacrylate (histoacryl+- bleu/indermil) Singer AJEM 2008: monomere qui polymerise contact de plaie, autre avantages de colle: pas de risque de piqûre accidentel, pas de nécessité de retrait des sutures (colle se resoud à 2 semaines), effet antimicrobien Farion Cochrane 2002, 2009: Tissue adhesives are an acceptable alternative to standard wound closure for reparing simple traumatic lacerations -Esthétique idem à sutures/tx standart: No significant difference was found for cosmesis at any time (aussi Young MJA 2005, Godin Md Qc 2006, Beam JAT 2008) -Moins de douleur: Pain scores (VAS difference - ̴13mm)… significantly favoured tissue adhesives -Temps procédure inférieur: Procedure time (mean time difference- ̴ 5min) significantly favoured tissue adhesives (aussi Beam JAT 2008) -Leger aug déhissence: Number needed to harm 40 (0.6% dans autre étude)
- Godin Md du Qc inférieure à 5cm Young MJA 2006 et www.rch.org.au less than 3cm
- Singer AJEM 2008: Éviter contact eau avec butylcyanoacrylate
- Pas eau 48h (octylcyanoacrylate ok), 72h pour steristrip Revoir si signe infection, dehiscence Pas antibiothérapie si propre (de plus, colle antibactérienne) sauf morsures, très sales, patients immunosupprimés
- Peut nécessité analgésie systémique (analgésique simple, opiacé) si plaie importante Doit suffisante et permettre temps de traitement incluant nettoyage et réparation (Young MJA 2005) Possibilité sédation, selon expérience clinicien: Nitronox ou midazolam (Young MJA 2005) Ad sédation en SOP si très complexe
- Uptodate 2011: cite une étude où anesthésie complete avec gel chez 85% (76% avec solution)
- Uptodate 2011: cite une étude où anesthésie complete avec gel chez 85% (76% avec solution)
- Cepada Cochrane 2010: Increasing the pH of lidocaine decreased pain on injection Nicks IJEM 2010: -buffering the lidocaine -warming the solution -injecting slowly -27-30 g needle will decrease the pain on injection (Également: Fein Pediatric 2012, Godin Md Qc 2006)
- Pas eau 48h Revoir si signe infection, déhiscence Pas antibiothérapie si propre sauf morsures, fracture ouverte, atteinte tendon, très sales, patients immunosupprimés