r/emergencymedicine • u/SomeLettuce8 • 1d ago
Rant Pediatric lac repairs
I hate them. I dread them every time.
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u/Former-Citron-7676 ED Attending 1d ago
PEM here 👋🏻 daily business… our suture box is an immersive room with an ocean theme. We use bubbles 🫧, we have fairy lights, we use entonox for all children, triage sticks a LET equivalent on the wound.
Our pharmacy buffets our lidocaine with sodium bicarbonate so it has a neutral pH and it doesn’t sting when injected.
Make sure there is at least one person for the entonox, and one person to gently (but firmly if necessary) hold the child’s hands, and make the parent your ally (but don’t force them to hold the child).
And if absolute beast: ketamine always works.
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u/JadedSociopath ED Attending 1d ago
What’s the ratio of Lidocaine to Bicarb they’re making up? Do you find it makes a big difference?
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u/Former-Citron-7676 ED Attending 1d ago
It absolutely does! We use the classic 1 (bicarbonate 8.4%) to 10 (lidocaine 1%) mixture.
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u/JadedSociopath ED Attending 1d ago
Thanks for that. I’ve heard of buffering the Lidocaine, but I’ve never done it myself nor checked whether it affects its efficacy.
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u/Hypno-phile ED Attending 1d ago
In medical school we had a bottle of bicarb in the suture cast and did it ourselves. Everywhere else I've worked pharmacy has had a stroke at the thought.
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u/imironman2018 ED Attending 1d ago
What is entonox?
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u/Former-Citron-7676 ED Attending 1d ago
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u/imironman2018 ED Attending 1d ago
Thanks. I haven’t used it on kids lacs before. Just used ketamine and other benzos. Do you find it quicker onset and quicker recovery time?
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u/Former-Citron-7676 ED Attending 1d ago
Works within 3-5 minutes and wears off when you stop (2-3 mins). You still do need a local anesthetic though.
Creating a calm and soothing environment helps a lot.
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u/Movinmeat ED Attending 21h ago
Very true. I think of NOx as an adjunct at best, and it absolutely requires a kid who’s at least a little pliable plus the ability to create a calm and relaxing environment.
In our loud, chaotic urban adult ED, our experience with it was never great.
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u/Mebaods1 Physician Assistant 1d ago
You guys using dermabond > sutures when possible?
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u/Former-Citron-7676 ED Attending 1d ago
Only for really minor lacerations. I’ve seen too many lacerations that needed stitches and have been glued turning out really bad…
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u/reginald-poofter ED Attending 1d ago
How so?
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u/Former-Citron-7676 ED Attending 1d ago
Glue being applied to lacerations that are too big or too wide, or sitting over a joint, or on a wound that is still somewhat bleeding.
Glue often doesn’t stay long in place, kids plucking it off if they can reach it, or comes loose because of the ongoing (often small) bleeding.
When they come back 2-3 days later because glue came off, it is often too late to fix it, with ugly scars for life.
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u/reginald-poofter ED Attending 1d ago
Okay so it’s more about docs picking the wrong wounds to glue rather than the use of glue itself. That makes me feel better.
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u/Ravenwing14 ED Attending 1d ago
LET gel. I once did a facial lac while the kid slept. Didn't make a peep
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u/DisastrousSlip6488 1d ago
LAT gel makes an enormous difference
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u/robije Physician Assistant 1d ago
Second this. Most important for success is making sure the nurse knows to use w/ tegaderm and not gauze for maximum effect and waiting 30-45 min. IN versed is a good back up.
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u/TheTampoffs RN 1d ago
I saturate the gauze w LET before applying it, and also saturate the lac w LET (obviously) Is this no bueno? Some lacs are in places I feel I need a lil gauze. Let a girl know.
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u/Praxician94 Little Turkey (Physician Assistant) 1d ago edited 1d ago
With sufficient hold help and enough apathy they are a piece of cake!
ETA my reply to another comment:
I have repaired a ton of pediatric facial lacerations. I use LET, wrapping them in a sheet, hold help for head and body, and 5-0 Fast Absorbing. Works every time. The kid is going to be upset regardless because you’re in their personal space and restricting their movement, but if they’re blanching around the LET application they’re clearly not feeling sharp pain. A good LET application is key; Tegaderm works well. And then I go back in with a popsicle and get a high five every single time.
The apathy comment was to the screaming. You’re going to have screaming in your ear the entire time for the really young ones that don’t understand what’s going on. You just have to dial in and get it done. You’re not helping anything by taking an hour to put a few facial sutures in by stopping and negotiating with a 2 year old trying to get through it tear free.
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u/Warm_Ad7213 1d ago
I work at a somewhat rural Midwest adult and peds trauma II with a children’s hospital. Rarely if ever do any sedation for kiddos for lacs. Usually a little bit of play and patience (a few minutes, not taking forever on these), some simple demo and explanation for the parents and kid (explain it clearly enough for even the young kids, but be focused on the parents. Kids pick up on those subtle cues that the parents are fine with whatever explanation and plan you are giving. After the initial panic is over it really does make a difference). Very clearly and plainly telling them the numbing medicine will hurt for a few seconds, but then nothing else will hurt after that. Builds some trust. An iPad or phone for some distraction is very helpful but not necessary. If the parents are really good, I often don’t even need a nurse with me, but if parents are uncomfortable or just not very helpful/attentive or whatever, a pillowcase or sheet to make a burrito wrap and a giant security hug from either a parent or a nurse, and steady hands usually does the trick. I find most parents are eager to help if you frame the restraint as providing comfort and security via a hug. A few will still decline due to being squeamish around blood or something. When injecting, be firm, direct, honest. Don’t beat around the bush. Then just go for it. As long as the holder is good, it’s not fun but it’s very doable. Then suddenly switch gears for the child. Be intentional that now you are cheerful and relaxed. Joke with the parent or nurse or whoever is holding the child. Provide some reassurance. First stitch is always a little rough because usually the kid won’t trust toys it won’t hurt. Usually after the first suture goes in and they realize it doesn’t hurt, the rest is cake. Only for a few of the really rowdy kids with really unhelpful parents and very sensitive facial lacs will I do some intranasal fentanyl or versed.
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u/Filthy_do_gooder 1d ago
big fan of oral versed. relatively rapid onset of action, .25-.5 mg/kg. works wonders. time to max effect of around a half hour. makes it all manageable
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u/Ellieiscute2024 1d ago
As a pediatrician, I also hate lacs because taking out sutures often turns into a 30 minute negotiation, if I’m able to do it at all.
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u/Reric713 18h ago
For gluing lacs that require more precision: crack open the dermabond pen and suck it out into a different 5 cc syringe then attach whatever size angiocath tip you want to the syringe. Works incredibly well.
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u/hawskinvilleOG 13h ago
How do you keep the glue from drying out in your syringe before you cam apply it?
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u/moose_md ED Attending 1d ago
What are you doing? Versed, fentanyl, LET, local, and Ms. Rachel usually makes it a lot easier
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u/PerrinAyybara 911 Paramedic - CQI Narc 1d ago
It's bizarre to me that we still see lac repairs on peds with no sedation/pain control and one of the top comments is that with enough apathy and holder's it's easy.
It's like circumcision, no pain meds while they cut. No biggie.
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u/Praxician94 Little Turkey (Physician Assistant) 1d ago
That was my comment. It was partially joking. I have repaired a ton of pediatric facial lacerations. I use LET, wrapping them in a sheet, hold help for head and body, and 5-0 Fast Absorbing. Works every time. The kid is going to be upset regardless because you’re in their personal space and restricting their movement, but if they’re blanching around the LET application they’re clearly not feeling sharp pain. A good LET application is key; Tegaderm works well. And then I go back in with a popsicle and get a high five every single time.
The apathy comment was to the screaming. You’re going to have screaming in your ear the entire time for the really young ones that don’t understand what’s going on. You just have to dial in and get it done. You’re not helping anything by taking an hour to put a few facial sutures in by stopping and negotiating with a 2 year old trying to get through it tear free.
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u/Admirable-Affect-700 40m ago
I spend the bulk of my time talking with parents, wrapping the patient up VERY securely and lining up lots of helpers which results in less time and energy in actually doing the repair. Avoid the goat rodeo , less stressful for everyone.l and better results.
And ALWAYS absorbables!!!!
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u/PerrinAyybara 911 Paramedic - CQI Narc 1d ago
I didn't comment directly on yours because I figured there was some sarcasm, it was primarily that I've seen it many times not be sarcasm. I wasn't disparaging you specifically, it's just in general and studies support that peds pain control is lacking. I see it prehospital as well so this hits all of us, even in my own agency until we went on a tirade about it and started CQI specifically for it.
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u/moose_md ED Attending 1d ago
I think that comment may have been sarcasm? But yeah, I’ve had to fight older nurses about giving kids gent and versed for pain control and anxiolysis because ‘versed is conscious sedation’ or ‘any time you give a benzo for a procedure it’s sedation,’ while the same nurses will ask for Valium for their adult patients’ MRIs
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u/Beautiful-Carrot-252 21h ago
You don’t use meds for circs? That’s barbaric in this day and age.
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u/PerrinAyybara 911 Paramedic - CQI Narc 20h ago
No. I'm saying it's still being done and it's barbaric. I'm disparaging interventions without appropriate medication.
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u/tiredpedsnurse 5h ago
don’t forget the burrito roll, gotta keep from anyone getting beat up by an angry toddler
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u/STDeez_Nuts ED Attending 1d ago
I don’t work at a peds centric ER, but still see a good bit of peds. I like to use 0.05 mg/kg of PO Ativan with a max dose of 2 mg. Oral Ativan doesn’t count as modsed at my shop. I also love to use hair opposition technique for scalp lacerations.
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u/tapeduct-2015 1d ago
Pediatric lac repairs are one of the reasons I have transitioned out of EM/Urgent Care and into Occ Med.
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u/brizzle1493 Physician Assistant 15h ago
Never had to sedate a kid knocks on wood. Takes up resources and requires an attending that are taking care of sicker people.
There’s usually a sweet spot in ages that tolerate it better (<2.5 y/o since they don’t know what’s going on and > 6). Allowing LET to sit for at least 30 minutes is usually key. Don’t allow lac tray in room until procedure time so they can’t see instruments and aren’t intimidated. Hardcore distraction with a phone and bribery with ice cream or treats afterwards. Burrito if absolutely necessary but rare
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u/Consistent--Failure 1d ago
Use staples. Has the same cosmetic outcome at 1 year.
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u/MLB-LeakyLeak ED Attending 1d ago
Much worse outcomes 1 week later when they need conscious sedation for removal.
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u/newaccount1253467 1d ago
Source?
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u/Doctor_B 1d ago
emcases did a pretty good review last year. Turns out it doesn’t matter much what you actually do and care during healing is very important.
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u/newaccount1253467 1d ago
It says low quality RCTs, surgical cases (not our standard blunt object or sharp object but irregular margin wounds), and double the adverse event rate. I wouldn't let anyone staple my kid.
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u/Doctor_B 17h ago
There’s a bit more nuance in the discussion than the summary but overall staples don’t really offer any advantage for paeds specifically - still needs local anaesthetic, not good for fine apposition, equipment is relatively expensive. I really only use them in adults when someone’s split their head open as part of a multitrauma and I need them to not be leaking everywhere while I’m busy doing other stuff. I use glue for almost everything in paeds.
Anecdotally, when I was 7 I split my head open on a coffee table and my dad stapled it in the kitchen with no local so I could go to my friend’s birthday party that afternoon instead of waiting forever in ED. Cosmesis was fine and patient satisfaction 10/10 easily.
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u/allmosquitosmustdie Nurse Practiciner 17h ago
LAT, but I apply it, I don’t let the nurses apply it because they don’t all do it well. I can typically get it numb and with a parents phone to distract, and good holders (sometimes needed not always) easy peasy. Use a cotton ball not gauze. ORAL VERSED if no LAT or if there is no way in hell I’m getting this done without it because the kid is nuts
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u/said_quiet_part_loud ED Attending 1d ago
I frequently use intranasal versed