22 Practical procedures: trauma







If needle thoracocentesis is attempted, and the child does not have a tension pneumothorax, the risk of causing a pneumothorax is 10–20%. Children who have had this procedure must have a chest radiograph, and will require chest drainage if ventilated.




22.2 CHEST DRAIN PLACEMENT


Chest drain placement should be performed using the open technique described here. This minimises lung damage. In general, the largest size drain that will pass between the ribs should be used.


Minimum Equipment



  • Skin preparation and surgical drapes.
  • Scalpel.
  • Large clamps ×2.
  • Suture.
  • (Local anaesthetic.)
  • Scissors.
  • Chest drain tube.
  • Underwater seal drain or Heimlich valve

Procedure



1 Decide on the insertion site (usually the fifth intercostal space in the mid-axillary line) on the side with the pneumothorax (Figure 22.2).

2 Swab the chest wall with surgical preparation or an alcohol swab.

3 Use local anaesthetic if necessary.

4 Make a 2–3 cm skin incision along the line of the intercostal space, just above the rib below.

5 Bluntly dissect through the subcutaneous tissues just over the top of the rib below, and puncture the parietal pleura with the tip of the clamp.

6 Put a gloved finger into the incision and clear the path into the pleura (Figure 22.3). This will not be possible in small children.

7 Advance the chest drain tube into the pleural space during expiration.

8 Ensure the tube is in the pleural space by listening for air movement, and by looking for fogging of the tube during expiration.

9 Connect the chest drain tube to an underwater seal.

10 Suture the drain in place, and secure with tape.

11 Obtain a chest radiograph.


Figure 22.2 Chest drain insertion: landmarks.


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Figure 22.3 Chest drain insertion: clearing the path.


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22.3 PERICARDIOCENTESIS


The removal of a small amount of fluid from the pericardial sac can be life saving. The procedure is not without risks and the electrocardiogram (ECG) should be closely monitored throughout. An acute injury pattern (ST segment changes or a widened QRS) indicates ventricular damage by the needle.


Minimum Equipment



  • Skin preparation and surgical drapes.
  • ECG monitor.
  • (Local anaesthetic.)
  • A 20 mL syringe.
  • Large over-the-needle cannula (16 or 18 gauge).

Procedure



1 Swab the xiphoid and sub-xiphoid areas with surgical preparation or an alcohol swab.

2 Use local anaesthetic if necessary.

3 Assess the child for any significant mediastinal shift if possible.

4 Attach the syringe to the needle.

5 Puncture the skin 1–2 cm inferior to the left side of the xiphoid junction at a 45° angle (Figure 22.4).

6 Advance the needle towards the tip of the left scapula, aspirating all the time (Figure 22.5).

7 Watch the ECG monitor for signs of myocardial injury.

8 Once fluid is withdrawn, aspirate as much as possible (unless it is possible to withdraw limitless amounts of blood, in which case a ventricle has probably been entered).

9 If the procedure is successful, remove the needle, leaving the cannula in the pericardial sac. Secure in place and seal with a three-way tap. This allows later repeat aspirations should tamponade recur.


Figure 22.4 Needle pericardiocentesis: angle.


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Figure 22.5 Needle pericardiocentesis: direction.


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22.4 FEMORAL NERVE BLOCK


Femoral nerve blocks are commonly used for acute femoral fractures. Blockade of the femoral nerve results in anaesthesia of the anterior thigh, most of the femur and knee joint, and the skin on the lower leg’s medial aspect.


Recommended Blocks



  • Blind fascia iliaca block.
  • Ultrasound-guided femoral nerve block.

The blocks above have replaced the blind femoral nerve block as they confer increased efficacy and safety. Available evidence in children demonstrates that ultrasound guidance improves the quality, onset, duration and success rate of peripheral nerve blocks and lowers the local anaesthetic volume needed. Refer to the sectional below on avoiding nerve injury.


Anatomy


The femoral nerve passes underneath the inguinal ligament, lateral to the femoral artery. The mnemonic VAN (vein, artery, nerve) going from medial to lateral, aids recall of the relationship of the femoral nerve to the vessels. The blocks are performed just below the ligament. At this location the nerve is covered by the fascia lata (a continuation of the inguinal ligament) and fascia iliaca, which separates it from the femoral artery (Figure 22.6).



Figure 22.6 Femoral region anatomy.


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These fascia layers explain why ‘blind’ injection of local anaesthetic near the artery, or injection under the fascia lata only, can fail – the fascia iliaca prevents the spread of the local anaestheic to the femoral nerve.


Surface Anatomy


The inguinal ligament runs from the anterior superior iliac crest to the pubic tubercle. The arterial pulse is felt halfway along this line, with the femoral nerve lying just laterally. Femoral nerve block is performed at the femoral crease, about one to two patient finger breadths below the inguinal ligament.


Local Anaesthetic


A long acting anaesthetic should be used. The dose of bupivacaine is up to 0.8 mL/kg of 0.25% (up to 2 mg/kg); maximum 60 mL of 0.25%. Use a 20 mL syringe with flexible minimum volume extension tubing attached to the needle.






Avoiding nerve injury


  • Aseptic technique
  • Use nerve stimulation over blind techniques
  • Use ultrasound and direct visualisation
  • Slow needle advancement
  • Do not elicit paraesthesia
  • Do not inject when the child complains of pain
  • Avoid forceful, fast injections; limit the injection speed to 15–20 mL/min
  • Use short bevel ‘blunt’ needles
  • Fractionated injections: inject smaller doses and volumes of local anaesthetics (3–5 mL), pause and aspirate (to check for blood) to avoid inadvertent intravascular injection
  • Do not inject when high pressures on injection are met; when injection of the first 1 mL of local anaesthetic proves difficult, abandon the injection, withdraw the needle completely and confirm its patency before reinserting
  • Use of a 20 mL syringe avoids the generation of high pressures




Fascia Iliaca Block


The fascia iliaca block is a modification of the femoral nerve block, and also blocks the lateral cutaneous nerve of thigh. It is simple to learn and a safe way to anaesthetise the femoral nerve in the emergency setting. The block is performed away from the femoral nerve and artery, and so carries a lower risk of neuropraxia or intravascular injection.


Equipment



  • A ‘blunt’ (short bevelled) 22 g block needle or an epidural needle to obtain an obvious ‘popping’ sensation as the fascial layers are breached.

Procedure



1 Mark on the skin the insertion points of the inguinal ligament, and the junction of the outer and middle third of the line joining these two points. The needle insertion point is one to two patient finger breadths below this point (Figure 22.7).
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on 22 Practical procedures: trauma

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