Little kids with lacs - intranasal versed?

[pinipig523]

For kids with lacs that you don't want to put down... What's your combo? Lortab and intranasal versed?

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[link2swim06]

Brutane?

At my hospital intranasal versed requires a sedation consent form and all of the airway equipment to be ready. This generally freaks the parents out enough that they opt for holding the kid down if they have the choice.

 

[pinipig523]

Yeah I hear ya... Had issues with multiple toe lacs a few shifts ago... Brutane doesn't hold down toes.

 

[deleted547339]

From easy to tough (obviously age also matters a lot)

Reassurance with topical --> child-life and local --> intranasal versed --> ketamine

I only go brutane if they are tiny and easy to papoose.

 

[deleted547339]

Brutane?

At my hospital intranasal versed requires a sedation consent form and all of the airway equipment to be ready. This generally freaks the parents out enough that they opt for holding the kid down if they have the choice.

That's crazy. You're using it for anxiolysis, not sedation....oh how I love hospital admin....

And isn't airway equipment always ready? Just roll the airway cart in the general vicinity and you can check that box off.

 

[RustedFox]

Brutane.

Kid has got to learn that life ain't all roses and unicorn farts.

 

[mauricekenter]

2mcg/kg of Fentanyl IN + 0.2mg/kg of Versed IN -> wait 15 mins and then go for it. I don't really find the IN versed to help much, but we are using 1/2 doses as I have seen other research papers use. We don't need procedural sedation equipment or documentation. Plus the nurses need to understand how to administer the IN mediation (i.e.; strongest concentration with half in each nostril and no more than a few mL total)

 

[shoal]

Just did a nailbed repair with in versed, brutane abd digital block. . . still easier just to ketamine them...

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[Perrotfish]

Is anyone here brave enough to just use intranasal Ketamine on all of them? How long do you guys watch after giving Ketamine?

 

[dotcb]

If I can't finesse it with coercion, papoose, local anesthesia, I given ketamine IM or IV, watch 45-90 min after.

 

[njac]

The biggest issue I've seen with anything intranasal is the physician/provider being in too big of a hurry to get the procedure done. I'm lucky if I can get 2 minutes to get the kid to settle down, and I'd be overjoyed if someone would give them 5.

So in turn I work with a bunch of people who aren't big proponents of intranasal meds because they've had negative experiences administering the med and then immediately doing a procedure on a non sedated kid who sleeps for 30 minutes afterwards between the sedation and exhaustion from the required brutane.

 

[Birdstrike]

Brutane.

Kid has got to learn that life ain't all roses and unicorn farts.

Brutane is the safest (and most time and resource efficient) sedative by far. Sedation is great when it's truly necessary, but ugly when one goes bad. Of course, in the ED you're prepared and trained with proper sedation, airway issues and monitoring, but you can google "pediatric dental sedation death" if you want a few reasons not to get too cavalier about pediatric sedation. With many of these sedations, you're treating parental anxiety/drama with some risk to the kid.

 

[la gringa]

I find that LET x3 applications 15-20 min apart will do at least 50% of your local, if not all in certain instances. then use an insulin syringe for your local, and lots of smoke and mirrors +/- brutane depending on the age. often add some lortab elixir to treat the parents if nothing else, and for pain control when they get home.

sedation takes up so much manpower at every shop i've been in that unless it's large/dysfiguring, i go with the above.

have had to play up the risks of sedation for many parents - the peds ED downtown at the peds hospital sedates more. they are staffed differently and have residents. makes a huge difference but creates these unrealistic expectations when they roll in my FS ED in particular.

 

[WilcoWorld]

These issues seem to hinge more on nursing comfort/protocols or parental anxiety than they do on patient safety or pain.

In order to use intranasal versed at my shop I'd have to jump through all of the same hoops required to give IV propofol and ketamine. As such I either do full sedation, or no sedation.

For Peds lac repairs I use either papoose + LET or I do a full sedation (usually IM ketamine for quick ones, IV ketofol for longer repairs).

 

[slystalone]

Never heard or thought of LET x 3 20 mins apart. Is that based on personal experience or is there a study floating around? I use it once and get okay results...

 

[la gringa]

LET x3 was handed down to me by another physician, i've used it many times. works well AND buys you a bit of time to see a few other pts while the LET works and before you're tied down w/ the repair. also parents know you're trying to address pain.... and time for lortab to work if given.

i've had a few instances where i did no additional local esp smaller scalp lacs. the increased vascularity works for you in that instance. like i said i usually touch up with tiny amounts of local using an insulin syringe. use a lot of smoke and mirrors for the more aware and alert kiddos.... never let 'em see a needle! feed them other terms! "it's so cold isn't it!"

 

[styphon]

I have had good experience with LET + papoose. I also do not let peds or adults "see the needle".

 

[Tenk]

Oral versed is also good and isn't always flagged in charts as sedation. I once had a kid who was just staring at a toy dinosaur the entire time I repaired a lac by his eye.

 

[turkeyjerky]

Ive had decent results with the combo of IN versed and fentanyl, terrible results when using only versed (they tend to get disinhibited and it seems to make things worse if anything--although I've always used .2mg/kg, not .4 so I'll have to look into dosing). Any advice on obtaining effective Brutane? It seems that 95% of the lacs I get are either facial or hands, and these can be difficult to hold still. Man do I hate tiny little hands

 

[coachB]

Oral versed is also good and isn't always flagged in charts as sedation. I once had a kid who was just staring at a toy dinosaur the entire time I repaired a lac by his eye.

Agreed, this seems to work quite well in my experience.

 

[ccfccp]

pillow to face prn twitching... works every time.

 

[Tiger26]

0.4 mg/kg IN versed with a max of 10 mg since you can't absorb more than 1 cc per nare of intranasal medication before your receptors are saturated.

Sedation is a matter of intent. My intent with IN versed is anxiolysis rather than sedation, meaning that it doesn't require the moderate sedation equipment.

Overall, this works really well, though I also use LET whenever possible.

 

[styphon]

Ive had decent results with the combo of IN versed and fentanyl, terrible results when using only versed (they tend to get disinhibited and it seems to make things worse if anything--although I've always used .2mg/kg, not .4 so I'll have to look into dosing). Any advice on obtaining effective Brutane? It seems that 95% of the lacs I get are either facial or hands, and these can be difficult to hold still. Man do I hate tiny little hands

I find wrapping the kid in a blanket w/ arms at the works well. You can often make it a game and before they know it they are unable to move their hands/arms. ie: "lay like a mummy" "we are going to wrap you up and turn you into a taco!" etc

No more little hands trying to grab needles!

 

[shookwell]

Oral versed is also good and isn't always flagged in charts as sedation. I once had a kid who was just staring at a toy dinosaur the entire time I repaired a lac by his eye.

This is my first line as well. Works well most of the time. Just make sure to warn the parents that the kid will be acting "drunk" for a while, that's something most parents can relate to and they don't freak out when you are done and the kid is still loopy. I'm also ok with sending the kid home still kinda sedated because of the quick peak of versed, as long as the parents are cool with it and seem reasonable.

 

[RPedigo]

I do 0.3 mg/kg of intranasal midazolam and LET x3 applications while I let the midazolam percolate in. I have had very good success with that. For facial lacerations I combine it with a cervical collar to prevent neck mobility. Ideally an iPad playing Dora the Explorer or something, too...

 

[BiOhAzArD1499]

For kids with lacs that you don't want to put down... What's your combo? Lortab and intranasal versed?

Nitrous and an iPad

 

[Angry Birds]

Can anyone give details about how they use Ketamine IM in such a situation? Hit 'em with something like 3 mg/kg? Good results? Seems like it would simplify things since you wouldn't have to hold them down for an IV.

 

[The White Coat Investor]

I used intranasal fentanyl the other day, 2 mcg/kg, and was very happy with the results.

 

[Droperidol]

I have on occasion used IM ketamine. 3 mg/kg for first dose followed by 1.5 mg/kg if needed. It gives good results but you may be holding afterwards for longer than you may want.


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[Groove]

I just really haven't had a situation where I needed anything other than some good brutane and nursing +/- papoose to hold a kid down in order to allow me to finish a procedure. I don't think there's anything faster than that.

I use ketamine on rare occasions and am at least curious about the intranasal versed/fentanyl. I may try it at some point.

 

[GeneralVeers]

Ketamine, especially for anything on hand or face. It's just not worth the time fighting with parents, and kids. Yes you are holding them for a while afterwards, but I can always go see other patients and just check back every 30 min or so.

 

[RustedFox]

Ketamine, especially for anything on hand or face. It's just not worth the time fighting with parents, and kids. Yes you are holding them for a while afterwards, but I can always go see other patients and just check back every 30 min or so.

Yeah, I like this too. I've never tried it; (I didn't have ketamine at my primary job site) for awhile - but this sounds like a giant physiological win. No airway depression, a stoned/funny kid, and minimal parental anxiety.

How much do I use ?

 

[deleted77919]

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[Docinthetrenches]

It's an option but honestly I agree with the posters about using "Brutane". It is clearly safer than doing conscious sedation and unless the lac is large and complicated, I stopped using any drugs with kids under about 10. Usually I use LET before I inject with some lido regardless.

 

[Angry Birds]

Yeah, I like this too. I've never tried it; (I didn't have ketamine at my primary job site) for awhile - but this sounds like a giant physiological win. No airway depression, a stoned/funny kid, and minimal parental anxiety.

How much do I use ?

I have Ketamine at my shop but it's way too concentrated, so I don't like to mess with it... Sucks because I would love to have that in my arsenal.

 

[njac]

I have Ketamine at my shop but it's way too concentrated, so I don't like to mess with it... Sucks because I would love to have that in my arsenal.

Yes, but the concentrated is good to have for IM and IN. Also good to have that much available for bigger patients.

We made the mistake of having two concentrations in the ED for about a week. Silly me, thinking that keeping them in separate Pyxis cabinets with huge concentration stickers would be enough.

This is why we can't have nice things.