Author: Jess Spedding / Codes: CC12, HAP34, PAP15 / Published: 17/09/2014
In the past, paediatric lacerations that required sutures often required admission and a general anaesthetic for wound closure. I wanted to think about how we can (or in many hospitals already do) provide timely, cost effective and acceptable management in the Emergency Department (ED) that avoids this paradigm.
PLEDGE: The ideal management of a wound that requires sutures is providing adequate analgesia and/or anaesthesia to allow wound cleaning, exploration and neat closure in a manner that the patient and family find acceptable
Having the tools, skills and personnel to do this in the ED not only reduces a young patients anxiety and distress but should be more acceptable to parents who often need to juggle various family and work commitments when their child requires a more lengthy hospital stay. In many cases, a complete episode of care within the ED also avoids the need for (and therefore the risks of) a general anaesthetic. Not only is this more acceptable to patients and parents, it triggers a cascade of savings for the NHS, as it avoids the following pathway:
- Transfer of patient by nurse / porter to ward
- Nursing admission to ward
- Second clerking by admitting team
- Anaesthetic doctor review
- Operating theatre usage and surgical and theatre staffs time
- Recovery nursing
- Post operative ward care
- And many more things Ive not thought of
So what things do we have in our ED armoury to fulfil the pledge?
1. Play Specialist For those of us lucky enough to have worked in an paediatric emergency department (PED) with a dedicated play specialist, we know of their mystical powers surrounding children you may hear the screams of a two year old as they book in, or witness the quivering wreck punching at the triage nurse as the calpol is syringed into their spitting mouth, only to return to the child once theyve been prepped by the play specialist and find them calm, relatively reasonable and able to cooperate. Standards for Children and Young People in Emergency Care Settings1 (a document authored by the Royal College of Paediatrics and Child Health, the College of Emergency Medicine, the Royal College of Nursing amongst many others) has as a standard of care that: EDs seeing more than 16,000 children per year employ play specialists at peak times or have access to a play specialist service. I had hoped to do my FCEM Clinical Topic Review on whether employing a dedicated play specialist for the PED saved the NHS money, through allowing various procedures to be completed safely and more quickly in the ED, but unfortunately very little research has been done. The one study that addresses the impact of a tailored play and distraction intervention in ED is American where play specialists are called child life specialists.2 This RCT looked at wounds requiring sutures and demonstrates significant reduction in patient anxiety and higher parental satisfaction in the intervention group as compared with no intervention group. But what no one has looked at to date is whether these reduced anxiety levels result in increased success rates of ED care, thus avoiding the need for admission for general anaesthesia to overcome a childs fearful opposition. Play specialists spend time with the patient, getting to know them, their likes, their fears. They negotiate with the child and family, and plan the best way to carry out an unpleasant or scary procedure, be that distraction techniques, role play, rewards or a whole host of other clever tricks. It may be that your department does not have a dedicated play specialist but we should make it our aim to find out if there is one with a responsibility to ED as there may be occasions when we can ask them to help out for a specific task, and the charge nurse and site manager may be very pleased to facilitate this if it means one less bed needs to be found for an admission.
2. LAT gel (Lidocaine Adrenaline Tetracaine gel) Many of us have come across LAT gel in our practice now and Im sure many have found it can be a fabulous aid to wound closure that avoids any form of sedation or anaesthesia in certain children. It is a gel that is put directly onto a wound and left for 20 minutes after which time it is numb enough for long enough to allow cleaning, exploring and suturing, avoiding the need for a needle to infiltrate local anaesthetic. St Emlyns have a great blog piece3 about their successes and there have been two Best BETs (both submitted and available on the website but not checked) on the subject which shed interesting light on the matter: The first is by Dr Katherine Williamson and asks In children presenting with facial lacerations can topical LAT gel avoid a general anaesthetic for repair?4 Unfortunately there is no evidence out there to support or reject this question. The second is by Dr Kirsten Walthall which asks In children with simple finger lacerations does LAT gel provide safe local anaesthesia5 (we have always feared adrenaline injection to digits). Thankfully she found two interesting papers that answer this question and both found that of all patients receiving LAT to fingers, none developed ischaemia.
3. Ketamine And for when distraction, play, and LAT just dont cut the mustard most Paediatric EDs offer a ketamine service to allow wound management in the otherwise uncooperative child. The College of Emergency Medicine published a guideline6 for its use in this context.
And finally: So I would hope that through prudent use of play specialist, LAT gel and if needed ketamine your child will have a well cleaned, meticulously explored and beautifully closed wound. Only for them to go home and put their grubby little fingers all over your handiwork
..So my final word is about topical antibiotics: When I was doing my paediatric sub-speciality post, I noticed that whenever we closed wounds wed send the child home with wound care advice, whilst if max-fax were the ones to close the wound (while we administered the ketamine!), the child would go home with a little tube of chloramphenicol eye ointment to apply to the wound three times a day. Again an interesting consideration, and one that I pressed the max fax doctors for evidence on. When I was met by silence I looked for myself, and found that, as with so many things in this piece, there was very little evidence pointing us either way. There is one paper that addresses this question and it is by Dire et al (Acad Em Med 1995).7 This group carried out a blinded trial of antibiotic petrolatum vs plain petrolatum (ie: vaseline) on sutured wounds in a military, adult population and found that using a triple antibiotic petrolatum reduced the risk of wound infection from 17% to 5%. This would seem to support the maxfax doctors management, but is not looking at our population, nor is it using the treatment we have readily available (chloramphenicol eye ointment is stocked by most EDs). SoI hope this piece has served to inform and interest and maybe even wet the appetite of budding Paeds ED enthusiasts to take on one of these poorly researched areas and ultimately to find the panacea of paediatric wound management and when you do, please let #FOAMed know!
- 1.Standards for Children and Young People in Emergency Care Settings 2012. Developed by the Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings. [Available at http://www.rcpch.ac.uk/emergencycare ]
- 2.Alcock et al. Evaluation of child life intervention in emergency department suturing Pediatric Emerg Care 1985 Sep 1(3): 111-5
- 3.Carley S. Please Use Less Ketamine- LAT gel at St Emlyn’s. St Emlyn’s. 2012 [Available at: http://stemlynsblog.org/lately-its-lat-gel/ ]
- 4.Williamson K. In children presenting with facial lacerations can topical LAT gel avoid a general anaesthetic repair? BestBETs 2010 [available at: http://bestbets.org/bets/bet.php?id=2198 ]
- 5.Walthall K. In children with simple finger lacerations does LAT gel provide safe local anaesthesia? BestBETs 2011 [Available at: http://bestbets.org/bets/bet.php?id=2198]
- 6.College Emergency Medicine Clinical Effectiveness Committee. Guideline for ketamine sedation of children in Emergency Departments.2009 (reviewed in 2016). [Available from: http://www.collemergencymed.ac.uk/Shop-Floor/Clinical%20Guidelines/College%20Guidelines]
- 7. Dire D, Coppola M, Dwyer D, et al. A prospective evaluation of topical antibiotics for uncomplicated soft-tissue lacerations. Acad Emerg Med 1995;2:4-10.