Basic Suture Skills Techniques

Pediatric Airway Management Techniques

Pediatric Orthopedic & Casting Techniques

Basic Suture Skills Techniques

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Prehospital Care:

- The goal is to achieve hemostasis and keeping the wound clean.

• applying pressure with clean bandages.
• Any visible foreign bodies should be left in place.
• Not to put any herbal recipe.

Basic Suture Skills Techniques

Emergency Department care:
Triage - Introduce – PPE – PAT assessment- if critical to be approached as ABCDE with urgent
management accordingly.

Initial Patient Assessment:

Primary Survey:
• Airway: airway obstruction, clear airway. If necessary, airway adjuncts or intubation.
• Breathing: RR, O2 sat, depth, any abnormal breath sounds. Administer oxygen.
• Circulation: pulse, Bp, CRT. fluid resuscitation for patients in shock.

Focused History and Physical Examination:

• History: mechanism, time of injury, and associated symptoms (e.g., dizziness, nausea).
• Physical Examination: wound exam, size, depth, and location. neuromuscular status in the
affected limb.

Neurological Assessment:
• Head Injuries: neurological examination, GCS and pupillary responses.
• Peripheral Nervous System: motor & sensory functions, around wounds near major nerves
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• Continues Vital Signs Monitoring
• Pain Assesment & Analgesia Administration accordingly.
• Considerations activation trauma Code for sever or Multiple Traumas.

Timing of wound closure:

- Primary closure: Scalp and face wounds can generally be closed within 12-24 hours of injury,

Basic Suture Skills Techniques

while closure of hand or extremity wounds should generally occur sooner, within 10 hours of
injury.
- Delayed primary wound closure: should be considered in wounds that are greater than 10
hours old, contaminated by large amounts of biological material or debris, or wounds that
may evolve over time, such as crush injuries or animal bites.

Wound characteristics that may need investigations:

• Suspected foreign body >> Ultrasound and/or x-ray.

Patient preparation:
• MOST important step to ensure successful procedure is child preparation.
• Use child-friendly language to describe the steps you will take to fix the cut with goal of no
pain.
• Engage parents be present at head of bed with child for distraction.
• Avoid showing the “metal” tools and needles.

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Wound preparation:
• «The Solution to Pollution is Dilution»
• Irrigation is the key to decrease wound infections.
• Irrigate wounds well.
• 50-100ml of water per centimeter of laceration length
• Tap water is safe and effective as saline, no difference in infection rates.

Basic Suture Skills Techniques

• Use 30 or 60 cc syringe with 20-gauge angiocath (may use medication cup as home-made
splash guard)
• May use Chlorhexidine 2% to disinfect skin.
• DO NOT use alcohol or related products (causes cell damage)
• DO NOT SHAVE the patient (increases infection rate)

Pain control:
• If available apply liberal amounts of L.E.T. using a piece of gauze or cover with an Op-Site/
Tega- derm for > 30 minutes. Can be used safely on wounds in any location on the body.
(EMLA cream apply only on intact skin)
• When infiltrating wound edges (i.e., not intact skin) with lidocaine, use a small needle (e.g.,
27-30 gauge) and inject slowly to minimize discomfort. Inject into the subcutaneous tissue,
then the dermal tissue.

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Pain control:
Maximum Maximum dose
Duration of
Agent dose without with Epineph- Note
action
Epinephrine rine
1%=10mg/ml
Lidocaine 5 mg/kg 7 mg/kg 30-90 min
2%= 20mg/ml

Basic Suture Skills Techniques

Bupivacaine 2.5 mg/kg 3 mg/kg 200 min 0.5 %=5mg/ml
• Lidocaine + epinephrine can be used on wounds in any location (max dose: 7 mg/kg,
1% lidocaine=10 mg/cc, 2% lidocaine =20 mg/cc).
• Add 1 mL bicarbonate per 10 mL lidocaine to buffer the solution to minimize the pain.
When to use what:
GLUE (Dermabond) SUTURE
Linear lacerations < 5 cm (If wound 3-5
Linear lacerations >5 cm
cm, ensure no gaping of the wound)
Easily opposable wounds Wound not easily opposable despite Steri-Strips™
No tissue loss Complex and/or non-linear laceration
Wound over large joint (i.e. knee) or with tension
No wound tension
on skin edges
Careful around eyes
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Steri-strips:
• Low-tension wounds.
• Good for skin tears.
• Can combine with Dermabond or sutures for extra strength.

Staples

Basic Suture Skills Techniques

• Similar scarring to sutures.
• SCALP! (Large trunk and extremity wounds where cosmetic outcome is less concerning;
discuss with parents for shared decision-making.)
• Must have high-quality stapler.

SUTURE:
Needle types and when to use:
• Reverse cutting: tougher tissues, less risk of cutting through tissue.
• Regular cutting: most used in acute setting, skin.

Suture types and when to use:

• Prolene or Ethilon(nylon): everywhere except inside the mouth
• Vicryl-rapide absorbable: under the skin-layered closure.
(Some advocate for children face, if unreliable for returning for removal)
• Chromic gut: inside the mouth, wet mucosa of the lip.

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 Non-Absorbable Absorbable
Braided Monofilament Braided Monofilament
Ethibond® Ethilon® Prolene® Vicryl® Vicryl® Monocryl® fast Chromic PDS II®
Silk absorbing gut (Polydioxanone)
(Polyester) (Nylon) (Polypropylene) (Polyglactin) rapide (Poliglecaprone)
gut

Area Size Type Days to Removal

Basic Suture Skills Techniques

Scalp Staples or 4-0 or 4-0 non absorbable 7
Ear 6-0 non absorbable 5-7
Eyelid 6-0 or 7-0 absorbable - non absorbable 5-7
Eybrow 5-0 or 6-0 absorbable - non absorbable 5-7
Nose 6-0 absorbable - non absorbable 5-7
Lip 6-0 non absorbable NA
Oral mucosa 5-0 non absorbable NA
Other Face/ forehad 6-0 absorbable - non absorbable 5
Chest/abdomen 4-0 or 5-0 non absorbable 12-14
Back 4-0 or 5-0 non absorbable 7-10
Extermities 4-0 or 5-0 non absorbable 7-10
Hand 5-0 non absorbable 7-10
Foot/ Sole 4-0 non absorbable 12-14
Joint (Extensor) 4-0 non absorbable 10-14
Joint (Flexor) 4-0 non absorbable 7-10
Vagina 4-0 absorbable NA
Penis 4-0 non absorbable 7-10
Scrotum 4-0 non absorbable 7-10

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• Antibiotics prophylaxis:
For immunocompromised pt, contaminated wounds, open fractures, bites, and extension to a
sterile site is a reasonable approach
Tetanus approach:
Post Wound Tetanus Vaccination
Clean, Minor Wounds All Other Wounds

Basic Suture Skills Techniques

Vaccination History
DTaP, Tdap, or Td TIG DTaP, Tdap, or Td TIG
Unknown or
Yes No Yes Yes
< 3 doses
No ( unless > 10 No ( unless > 5
≥ 3 doses years since last No years since last No
booster) booster)
Abbreviations: DTaP, diphtheria, tetanus, and acellular pertussis; Td, adult tetanus and diph-
theria; Tap, combined tetanus, diphtheria, and pertussis; TIG, tetanus immune globulin.

Wound characteristics that need specialty consultation:

• Neurovascular compromise
• Tendon injury
• Vermilion border that is complex or unable to approximate
• Ear/nose laceration crossing cartilage.
• Eyelid laceration needing suturing.
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WOUND CARE (give patient handout):

• Keep wound dry for 24 hours (glue & sutures)

• Do not pick at or try to remove glue until wound more than 10 days old.
• Wounds take 3 months to regain most of their tensile strength; consider Steri-Strip™ if high
risk sport activities.

Basic Suture Skills Techniques

• Once glue or sutures fall off or are removed, instruct to use sunscreen and gentle massage to
optimize healing and wound cosmoses for 1 year.
• Counsel that wound red x 6 months, then clears to skin color by 1 year.
• If signs of infection (red, tender, pus), seek medical care

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Pediatric Airway Management
Techniques

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Emergency Department care:

Triage - Introduce – PPE – PAT assessment- if critical to be approached as ABCDE with urgent

Pediatric Airway Management Techniques

management accordingly.

Initial Patient Assessment:

Primary Survey:
• Airway: airway obstruction, clear airway. If necessary, airway adjuncts or intubation.
• Breathing: RR, SPO2, depth, any abnormal breath sounds. Administer oxygen.
• Circulation: pulse, BT, CRT. fluid resuscitation for patients in shock.

Focused History and Physical Examination:

• assess for difficult airway intubation.
• (AMPLE, syndromes, hypertrophy tonsils, trauma, obesity, snoring)

Attach patient to cardiopulmonary monitoring and vital sign should be monitoring (sp2, HR, BP,
ECG and capnogram).

Ask for another subspecialty needed during intubation.

- Respiratory therapy
- Early Consultation Expert like anesthesia, ENT if difficult airway intubation anticipated

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Equipment Preparation: “SOAPME”

S: Suction: tonsillar tip and different sized tracheal suction catheters.

Pediatric Airway Management Techniques

O: Oxygen: Pre-oxygenating the patient with 100% SPO2 will increase the time available to
(Safe Apnea).
A: Airway: to choose Age-appropriate equipment.
P: Pharmacology: The common medications used in RSI
ME: Monitoring Equipment
• sp2, HR, BP, ECG and capnogram.
• Frequent blood pressure checks should also be performed.
• Confirmation with a capnometer (qualitative or quantitative) for end tidal CO 2

Checklist Age-appropriate equipment:

Face Mask / ventilation bags. capnometer (qualitative or quantitative)
O2 Sourse chest x-ray
laryngoscope handles and blades.
endotracheal tubes
stylets
oral airways
Rescue equipment (LMA, video laryngoscopes, surgical airway, bougie.
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Measures:

• Estimated wight by Broselow tape.

Pediatric Airway Management Techniques

LARYNGOSCOPE BLADE SIZE:
• Premie / Newborn: Miller 0.
• Infant – 2 years: Miller 1.
• 2 – 8 years: Miller 2.
• > 8 years: McIntosh 3.

Endotracheal Tube Selection

Uncuffed Cuffed

Infant (<1 year) 3.5 3.0

1-2 years 4.0 3.5
>2 years (Age by year/4) +4 (Age by year/4) +3.5
Size= internal diameter in millimeter

• Insertion Depth: Depth of insertion from the lip (cm) = 3 x ID of ETT (mm).
• Estimated Foley Cath size: 2 X ID of ETT (mm).
• Estimated Chest tube size: 4 X ID of ETT (mm).
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Pharmacology:
Pre-treatment
medication Dose remarks

Pediatric Airway Management Techniques

Indications to use:
- infants < 1 year
0.02 mg/kg, IV/IM. Max 0.5 - children 1-5 years + 1 dose of succinylcholine,
Atropine
mg/dose - children > 5 years + 2 doses of succinylcholine.
- Bradycardia.
- With Ketamine to decrease oral secretions
Lidocaine 1.5 mg/kg IV. Maximum dose 100 mg.
Sedation
Midazolam 0.1- 0.2 mg/kg IV
Ketamine IV: 1-3 mg/kg. Not to give infant < 3 months
Reduces cortisol production but clinical significance with
Etomidate 0.3-0.4 mg/kg
a single dose for rapid sequence intubation is unclear
2.5 – 3.5 mg/kg IV. Max
Propofol Risk of Hypotension < 6 months of age
50m per dose
Paralysis

- Infant: 2.0 mg/kg Cholinesterase deficiency - muscular dystrophy Family

Succinylcholine history malignant - hyperthermia Hyperkalemia - ate crush
- Child/Adult: 1.0 mg/kg. injurie - burns (not initial presentation)
- prolonged half life
Rocuronium 0.6-1.0 mg/kg IV
- Reversal agents: sugammadex

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Steps to intubate:
1- Identify oneself. 17- colorimetric end-tidal CO2 detector
2- Call for help. 18- Wear mask with eye protection
3- Put gloves on hand 19- Call for sedative and/or narcotic

Pediatric Airway Management Techniques

4- Open airway with head-tilt chin-lift or jaw 20- Call for paralytic medication.
thrust within first 15 s 21- Confirm intravenous access is functional
5- Choose right size mask.
22- Confirm team crew at specific task
6- Check O2 source is turned on
23- Ask for blood pressure cycle measurement before
7- Apply mask correctly (C E Technique)
induction
8- Provide bag and mask ventilation to see chest 24- sedative/narcotics to be given.
rise 25- Cricoid Press not routinely recommend
9- Ask for blood pressure measurement during 26- Stop bag and mask ventilation at correct timing (after
bag and mask ventilation paralyzed) for intubation
10-Decide to intubate within 60 s after bag and 27- Hold laryngoscope with left hand
mask ventilation is started Push the tongue to Lt side
11- Notify the team for intubation 28 - Be able to visualize a vocal cord
12- Call for suction system 29 - Intubate in trachea
13- Call for oral airway.
30 - Primary confirmation of endotracheal intubation
14- Call for endotracheal tube
15- Correct size of endotracheal tube is called 31- Secondary confirmation of endotracheal intubation
16- Call for laryngoscope 32- Holding endotracheal tube until it is secured

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Steps to intubate:
33- Call for chest x-ray
34- Confirm & adjust endotracheal tube placement based on chest x-ray

Pediatric Airway Management Techniques

35- React to hypotension after intubation
36- post intubation sedation
37- connect to MV
38- shift patient to PICU

Confirm appropriate placement of the ETT:

• Water vapor in the ETT during exhalation
• Equal breath sounds over both lung fields in the axillae.
• No audible breath sounds over upper abdomen (stomach)
• Symmetric bilateral chest wall rises.
• Colorimetric change in End-tidal CO 2 detector – purple (no CO2) to yellow (there is CO2)
may be absent in cardiopulmonary arrest despite correct ETT location.
• Sustained improvement in O 2 saturation
• Chest radiograph

Complications In the Intubated Patient:

• D- Dislodgment: Mainstem bronchus or esophagus.
• O- Obstruction: Secretions, blood, foreign body, vomitus, kinking of ETT.
• P- Pneumothorax: Decreased or absent breath sounds over the affected lung fields.
• E- Equipment: Failure of ventilator, power supply, oxygen supply, etc.
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Pediatric Orthopedic & Casting
Techniques

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 ATLS Approach

At the beginning:

Pediatric Orthopedic & Casting Techniques

Introduce yourself wearing PPE
PAT assessment – if need urgent management-
put C collar and backboard.
Push the Pt to critical bed. And connect to monitor.
connect to non-rebreather mask.
assign the team, ask nurse to insert IV line.
check weight by Breslow tape - check monitor and take vital signs

If EMS call on the way to bring a trauma patient:

ask EMT (Pt age, mechanism of injury, V/S Summary of injuries).
Estimated time to arrive.
based on that information you can decide about:
preparations, equipment, and team.
Early Activation of Trauma Code Team.
notify pharmacy, radiology, and blood bank.
If High number of injuries to activate disaster Code. (Based on the institutions policiy)

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Start primary survey:
A: airway:
Is the Patient response?

Pediatric Orthopedic & Casting Techniques

Is the Airway Clear? Maintainable? Secretions? Blood? FB? Facial fx?
Tracheal or laryngeal injury? Neck trauma? Sounds(stridor)? Inhalation Burn?
Intervention:
Apply C collar if not Applied before.
position airway by jaw thrust, suction, bag mask valve.
intubation [assess vital signs before intubation] “Maintain in-line cervical spine
immobilization during intubation.”
B: breathing: chick for O2 sat- RR then
Inspection: work of breathing-symmetrical- tracheal position chest wounds
Auscultation: air entry- breath sounds- heart sounds
Palpation: Flail chest – crepitus- fracture
Percussion: dullness- hyper-resonant
EFAST: thoracic and subxiphoid views
Intervention: high flow O2- BMV-intubation [assess vital signs before intubation]
if tension pneumothorax: needle decompression 2nd intercostal space mid-clavicle site.
Then insert Chest Tube to 4th /5th intercostal space in the mid-anterior Axillary line
and connect to underwater seal and do chest x-ray - pericardiocentesis.

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 Start primary survey:
C: Circulation: chick for:
HR-BP- CRT- Pulse central and peripheral- skin color and temperature.
Pediatric Orthopedic & Casting Techniques

Pediatric Orthopedic & Casting Techniques

ECG- bleeding- abdominal tenderness- pelvic instability
EFAST.

Intervention:
Ask the Nurse to insert 2 large pore IV line- IVF 20 ml/kg bolus once then if need PRBC
transfusion.
Do trauma panel: (CBC-Coagulation profile- blood group and cross match- LFT- amylase-
Renal Function- VBG- lactate- urine for RBC and blood.
PRBC (the best is cross match> type > O-ve (O -ve for children and women in childbearing
age, other we can give O +ve)-
If multiple PRBC units 40 ml/kg over 12 hours given, Consider (massive blood transfusion
protocol) PRBC-PLT - FFP 1-1-1”
to consider tranexamic acid “within 3 hours” from trauma –
Control external hemorrhage.
Stabilize pelvis by binder or bed sheath “technique?”
if patient unstable, hypotensive and can’t controlled the bleeding to shifted urgently to OR.

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Start primary survey:
D: GCS-AVPU-pupils “equal, reactive. size”, glucose level – signs of basilar skull fracture- signs
of neurogenic shock – signs of high ICP, herniation or lateralization.

Pediatric Orthopedic & Casting Techniques

Intervention:
C collar- intubations – high ICP management
neurogenic shock-norepinephrine for hypotension and atropine for bradycardia”

E: expose patient fully and prevent hypothermia- looks for bleeding, bruises, fx or deformity.
Log rolling for spinal tenderness and step off and check anal tone and rectum for blood “for
perforation and neurogenic shock.”
Intervention:
remove backboard if log rolling is normal “keep it as pt might need transfer for CT or OR”
1ry Survey Adjuncts: ECG-OGT “not NGT” – folly catheter if no urethral injury – AP CXR and
pelvic x ray – EFAST – VBG - ventilatory setting–CO2 monitor.

Secondary survey “Never do it if pt is not stable”

AMPLE [mechanism of trauma, vaccination for tetanus]
Head to toe exam [looking for minor traumas]
Adjuncts: spinal x ray – CT – contrast urethrogram- angiography – extremity x ray

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 Orthopedic Fractures and Casting
History:
• Chief complaint, Mechanism of injury. OPQRST (Onset, Provoking/ alleviating factors, Quality/
Quantity, Radiation, Site and Timing)
Pediatric Orthopedic & Casting Techniques

Pediatric Orthopedic & Casting Techniques

• Constitutional symptoms- fever, night sweats, fatigue, wt. loss.
• Referred symptoms, AMPLE history (Allergies, Medications, past medical history, last eaten
Events leading to).
Physical Examination:
• Look: SEADS (swelling, erythema, atrophy, deformity and skin changes).
• Move: Active then passive range of movement (ROM) for affected joint(s) and joints
• above & below.
• Neurovascular tests: Pulse, sensation, reflexes, power (0 to 5).
((Look for Any signs for non-accidental trauma))
Investigations:
• Plain x-ray: AP, lateral and oblique
• It is very important to get correct views for proper diagnosis.
• X-Ray rule of 2s:
- 2 sides= bilateral (comparison views in children when in doubt)
- 2 views= AP + lateral
- 2 joints= joint above + below
- 2 times= before and after reduction
• Blood: CBC, Grouping
• Aspiration: aspirate fluid from joint for analysis
• Ultrasound where appropriate
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 Orthopedic Fractures and Casting

Cast materials:
• Plaster casts can be molded to arm or leg.

Pediatric Orthopedic & Casting Techniques

• Fiberglass casts are more durable and lightweight than plaster casts

Cast types:
• slab : plaster encloses partial circumference extremity.
• cast : plaster encloses full circumference of extremity.
• spica : plaster include trunk and one or more extremities
• brace : plaster / material which can allow motion at adjacent joint.

equipments needed for the cast:

Large pads and plastic sheets
Plastic covered pillows
Fabric stockinette (1st inner layer) size (UL 5 cm) (LL 7.5 cm)
Webril cotton wool roll (size (UL 5-10 cm) (LL 10-15cm))
Plastic bowel filled with lukewarm water (the warmer the water the faster the cast will set).
Heavy duty scissors

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 Orthopedic Fractures and Casting

Applying Backslap:
• Apply stockinette over the limb with extra inches avoid wrinkles,
Pediatric Orthopedic & Casting Techniques

Pediatric Orthopedic & Casting Techniques

• Unroll the webril circumferentially, roll layers should overlap by 50%
• Use double thickness for both plaster ends and any bony prominences.
• Cut a hole/slit for the thumb if required.
• Apply extra squares over any bony prominences to avoid pressure sores.

techniques of Backslap application:

• correct width & length required longitudinally along the limb.
• Fold the plaster sheet to the create required layers – layers required– (UL 8 layers) (LL 12
layers)
• Cut plaster sheet to size.
• Immerse the plaster into the lukewarm water and hold it under until the bubbles stop.
• Drain the plaster until the drips stop (do not wring it out)
• Place the slab longitudinally in position over limb (fold any un‐neat edges)
• Mold by rubbing it smooth.
• Turn the ends of the webril back over the ends of the plaster.
• Unroll the broad gauze bandage circumferentially.
• Hold the limb is in the correct position for approximately 5mins until the plaster hardens

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 Orthopedic Fractures and Casting

Prescriptions, Instructions of the casting and follow up plan.

Pediatric Orthopedic & Casting Techniques

• Thank patient and cover them.
• Bin all waste and clean area
• resting triangular or high‐arm sling
• Once the backslab/cast is set check :
- No sharp edges
- Correct positioning
- Comfortable for patient,
- Distil neurovascular assessment and tendon function.
• Post‐cast X‐ray
• 24 hours cast check.
• Give the patient a leaflet and instructions for ED assessment (including
- numb/painful/cold/discolored, plaster must be kept dry and that, for weight
- bearing‐lower limb plaster casts, they must not weight bear for 2 days
• Fully document in notes and sign cast prescription
• Book follow up appointment

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 Pediatric Orthopedic & Casting Techniques

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BEST 3N1 Team
With best wishes