Peds tricks and tips

[caligas]

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who has good peds tricks?

What’s your go-to when they spit out the versed and they fight the mask but you don’t want to go all ground-and-pound on them?

(I’m talking beyond cherry chap stick and trying to convince them that it’s a “space mask.”)

 

[Iso4ane]

who has good peds tricks?

What’s your go-to when they spit out the versed and they fight the mask but you don’t want to go all ground-and-pound on them?

(I’m talking beyond cherry chap stick and trying to convince them that it’s a “space mask.”)

If they are crying harder, they go to sleep faster.

 

[ZzzPlz]

Cartoons on my iPhone usually work

 

[btbam]

If they are crying harder, they go to sleep faster.

But what if they are shunting R to L ?

 

[Ezekiel2517]

Kids are nothing but tiny adults.

 

[sigrhoillusion]

who has good peds tricks?

What’s your go-to when they spit out the versed and they fight the mask but you don’t want to go all ground-and-pound on them?

(I’m talking beyond cherry chap stick and trying to convince them that it’s a “space mask.”)

Once you get them to sleep, no matter how much they fought you, always announce to the OR staff that you are the winner and STILL the undefeated champion of the world! At least that's what I do...

 

[BobLoblaw78]

Hold them in your lap. Let them turn up the knobs and mess with the machine. Have someone by to hold the child's hands down if they continue to fight after all else fails (but usually you can just use your left arm that is holding them). Cross your leg over their legs to hold their feet down. Hold the mask over their face with your right hand (while they are sitting on your left side). Pushing the mask into them if necessary which also pushes them into you. This just helps keep them more secure. Works like a charm once you have tried it several times.

Also, so many people place the mask on their face initially. If they look anxious, just hold the mask a cm away. They will still get a lot of the N2O. It might take an extra minute but it is well worth it! At least enough to chill them out before you up the sevo. If you push a mask down on my face, I am probably going to pull away!

Also, I put cartoons on the monitors. Works great if you have that capability. Pull the monitor right up to them and they will zone out like tiny adult zombies! Happy Halloween!!!

 

[DirtDocMD]

Max sevo. Mask in left hand. Thumb and forefinger of right hand on the temples of their head, web of hand over forehead (so many people want to “cradle” their head, which doesn’t work as well to keep them from shaking their head left to right). If the nurse can hold the hands for 10 seconds, I win....

If a big autistic or unruly kid, ketamine dart, or if they’ll drink, combo po versed/ketamine works great, if you can wait the 30 mins it takes to really soak in.

 

[cowbydoc]

For my big autistic kids I pour out 2/3 of a cranberry juice cup and put the versed in the cup all while leaving the foil cover intact. I then roll the the foil cover back over the juice cup and give it to the parents to give to the kid. If they say it tastes funny I tell them it’s hospital juice and a little different. This works pretty well and avoids a ketamine dart that they WILL remember and come more worked up next time.

Great vein finder for 4y.o. And younger:
Amazon product ASIN B00T57K2ZW

 

[OneTyme]

Choke slam. Works every time.

 

[deleted59964]

distraction works better than positive reinforcement. ipad, a good. story, whatever is a start.

if won’t take oral premed - intranasal dexmed is nice (but need time for it to work) - i prefer to intranasal midaz because midaz burns

if combative with intranasal premed, consider rescheduling ... later that day if they may take oral premed with some nagging by mum... sometimes for another day if you think it won’t be the same again next time

i think IM ketamine is kinder than pinning down a child that is old enough to remember... every time i pin a kid down (that’s old enough to remember) i regret it.

 

[WholeLottaGame7]

Take the mask off and let them put their mouth around the elbow. Or just hold the elbow up to their face while they watch cartoons for a bit. Can give them some control but know when to draw the line; a lot of kids really know how to stall and draw things out. Agree with JobsFan, for the bigger kids, sometimes the IM dart entails less drama than trying to force them to drink something or holding them down.

Blind saphenous and blind 4th/5th knuckle PIVs are lifesavers.

Use the Miller blade like a Mac and put it in the vallecula to flip the epiglottis up out of the way.

Never trust an ex-23/24 weeker.

 

[btbam]

Can also mix Ketamine with a little bit of Sprite and let them drink it. Trying to dart a 110kg autistic teenager isn't my favorite way to get a workout.

 

[deleted87051]

Can also mix Ketamine with a little bit of Sprite and let them drink it. Trying to dart a 110kg autistic teenager isn't my favorite way to get a workout.

That sounds like quite a cocktail.

 

[Hoya11]

distraction works better than positive reinforcement. ipad, a good. story, whatever is a start.

if won’t take oral premed - intranasal dexmed is nice (but need time for it to work) - i prefer to intranasal midaz because midaz burns

if combative with intranasal premed, consider rescheduling ... later that day if they may take oral premed with some nagging by mum... sometimes for another day if you think it won’t be the same again next time

i think IM ketamine is kinder than pinning down a child that is old enough to remember... every time i pin a kid down (that’s old enough to remember) i regret it.

Plan a : po versed
plan b : IM versed (usually combative kid)
plan C: IM ketamine (usually combative/autistic adult)

i dont understand the need to do intranasal, if your going to get that close, give a shot IM no?

 

[deleted59964]

Plan a : po versed
plan b : IM versed (usually combative kid)
plan C: IM ketamine (usually combative/autistic adult)

i dont understand the need to do intranasal, if your going to get that close, give a shot IM no?

kids can be surprisingly cooperative with intranasal sometimes, as long as the intranasal premed doesn't burn it can be an OK experience for the child & parent.

If the child refuses the intranasal premed, then I don't force it.
I then consent the parent for giving the child IM Ketamine, and get them to distract the child, I sneak up from behind and do the injection (through clothes if necessary) , they cry - abuse me for 30 seconds - then lose consciousness.

so for me my premed escalation goes like this

Plan a - po midazolam
Plan b - intranasal dexmed
Plan c - IM ketamine

 

[deleted162650]

Agree with distraction being the best medicine. Part of my pre-op interview is "What's your favorite show?" and they get to watch that on my phone from pre-op until they're asleep. Also, maybe I'm in the minority here, but I don't like to give any pre-med unless it's reeaaaallly necessary (special needs, kid completely losing his **** in pe-op, kid that will need multiple procedures, etc.). I think that especially for short cases (BMT/T&A/etc) the pre-med makes for a rockier PACU course with more delirium, screaming, etc.

 

[propadope]

I can’t remember the last time I used PO midazolam on a child. If they are uncooperative they usually refuse it or spit it out. So I either do IM versed
and /or ketamine or mask with parent in the room.

Cartoons for younger kids or nintendo for older ones.

Parent usually present (unless parent is difficult to reason with). If small then mask induction with child in parents lap with parent hugging child with arms restrained. Assistant with hands on either side of child’s head to prevent turning.

IN midazolam is not pleasant (worse than IM). IN precedex takes too long.

I ask the parent what they prefer if child is uncooperitive a) restraint or b) IM. I tell them that IM can often be less traumatic.

For IM I have the child on the parents lap with the child facing the parent, head turned to the opposite side. I tell the child about the poke right before I do it to avoid trust issues.

 

[rakotomazoto]

Agree with distraction (phone/tablet/monitor) to hopefully avoid getting stuck in PACU waiting for oral versed to run its course. Oral versed for long cases, intranasal meds if PO isn't an option and its going to be a long case. Precedex is slow but works, I have also used intransal fentanyl, which is also a nice way to treat pain in really quick procedures where placing an IV at all is just a waste of time.

 

[Laryngophed]

Take the mask off and let them put their mouth around the elbow. Or just hold the elbow up to their face while they watch cartoons for a bit. Can give them some control but know when to draw the line; a lot of kids really know how to stall and draw things out. Agree with JobsFan, for the bigger kids, sometimes the IM dart entails less drama than trying to force them to drink something or holding them down.

Blind saphenous and blind 4th/5th knuckle PIVs are lifesavers.

Use the Miller blade like a Mac and put it in the vallecula to flip the epiglottis up out of the way.

Never trust an ex-23/24 weeker.

I do the mouth around the elbow for adults who are too claustrophobic for the mask too. Preoxygenation doesn’t require a mask.

 

[deleted87051]

I do the mouth around the elbow for adults who are too claustrophobic for the mask too. Preoxygenation doesn’t require a mask.

What if they breathe through their nose?

 

[propadope]

That sounds like quite a cocktail.

Do you put it in a pineapple or coconut?

 

[deleted59964]

I do the mouth around the elbow for adults who are too claustrophobic for the mask too. Preoxygenation doesn’t require a mask.

Me too - good for facial fractures and bushy beards as well

 

[somedumbDO]

Best peds tip ever...if they are sick pawn it off on your junior partners!!

 

[Sublimazing]

IM ketamine dart cocktail works everytime and in 2-5 minutes. I see little reason to do anything else. The only minimal downsides are some parents get emotional when they see the nysragmus and the ketamine/glyco/peds combo gets that heart rate up and can precipitate faster desats should they go apneic/obstruct/spasm.

I experimented with IN dex and it works but not as quickly and not as definitively (in my hands). PO versed is fine if you work in academics (or maybe if you oversee CRNAs) and have time to fiddle fart around.

 

[MirrorTodd]

This trick would be pretty legendary if one could pull it off. Fill one balloon up with helium and another with sevoflurane. Then challenge the kid to see whose voice can go higher. (Dont mix up the balloons).

*obviously this is tongue in cheek*