Reduction of a Supra-Condylar Fracture of Right Humerus - Case Study Example

CARE STUDY OF: A SIX YEAR OLD BOY, MICHAEL, IS BROUGHT TO THEATRE FROM THE EMERGENCY DEPARTMENT FOR OPEN REDUCTION OF A SUPRA-CONDYLAR FRACTURE OF HIS RIGHT HUMERUS. Student Name: Institution: Course name: Instructor name: Date due: Assignment: Care Study This study presents a case study of a six year old boy, Michael, who is brought to theatre from the Emergency Department for open reduction of a supra-condylar fracture of his right humerus. He is accompanied by his mother’s partner who reports that Michael had fallen from a slide while playing in a local park. Michael is withdrawn and tearful and has a large bruise on his forehead, but aside from several old bruises and scars on his arms and legs he is otherwise healthy. Treatment of Traumatic Injury in Children Supracondylar fractures are common paediatric injuries caused by accidental trauma (Diesselhorst et al. 2013, Finucate et al. 2011). The types of treatment for paediatric patients mainly depend on the degree of the fracture (Persiani et al. 2012; Gwinnutt 2008; Benson et al. 2010). This paper will critically discuss elements involved in the treatment of traumatic injuries in children. Furthermore, the study will also analyse aspects related to the psychosocial care of children in hospitals, and legal and ethical issues related to paediatric anaesthetics. The fundamental procedures used in paediatric operations will be discussed. These procedures will cover pre-operative, intra-operative and post-operative stages of managing airwaves, homeostasis, pain, and surgical interventions required. a. Airway Management Paediatric studies (Finucate et al. 2011; Gwinnutt 2008) revealed that surgical treatment of traumatic injuries in children requires precautions due to the complexity of children’s airway. According to Finucate et al. ( 2011), children have small airway diameters that create difficulties. Guidelines provided by the Association of Paediatric Anaesthetics of Great Britain and England require anaesthetists to be who possess expertise in dealing with the patient’s age, illness and co-morbidities (APAGBI, 2013). According to the guidelines, paediatric anaesthetic procedures should be held by anaesthetists who have “regular commitments to elective paediatric neuroanaesthesia and who have trained to the equivalent level identified in the CCT” (P.40). The studies further (Gwinnutt 2008; Benson et al. 2010; Finucate et al. 2011) revealed that paediatric anaesthesia equipments and drugs ought to be assembled before operation procedures, including paediatric defibrillator paddles and equipments for recording abnormal cardiac movements (Gwinnutt 2008). Tracheal intubation is an important component in successful management of the paediatric airway (Finucate et al. 2011). Anaesthetics should develop airwave management plan for the patient and pre-determine intubation indicators Choi et al. 2012). Indicators such as head injuries would require pharmacological interventions such as Rapid Sequence Intubation (RSI) (Walker, 2013). Therefore, establishing tracheal intubation indicators should be the first step to basic airway management. For most paediatric cases, anaesthetists should consider RSI as an emergency medication supported by general anaesthesia (Choi et al. 2012). RSI should be designated in paediatric patients who demand tracheal intubation but are highly prone to pulmonary aspirations of gastric filling. Airway differences also expose paediatric patients to upper airway obstruction (Allen et al. 2013). When lying down, paediatric patients may experience neck flexion and airway obstruction due to enlarged occipital lobes (Walker 2009). As a result, increased flexibility in the trachea results in to pressure on tracheal rings causing airway obstruction (Allen et al. 2013). When conducting RSI (Priebe 2010) suggest that the anaesthetic practitioner should ensure that cricoid pressure is maintained as of the instant of chemical paralysis until the confirmation of endotracheal intubation so as to avoid insertion of pressure in the tracheal rings. During the induction of anaesthesia, Gwinnutt (2008) suggests that anaesthetics should be aware of the implications of the muscle paralysis and the requirement to use an endotracheal (ET) tube. This needs to be considered in relation to the transmission of short electrical nerves through the skin for effective pain management. In addition, anaesthetics should use anti-sialagogues drugs to manage secretions in the airway (Hagberg et al. 2007). b. Maintenance of Fluid and Electrolyte Balance Electrolytes play a fundamental role in maintaining homeostasis by regulating neurological functions, oxygen delivery, fluid balance and acid-base balance. Maintaining fluid and electrolyte balance is fundamental to paediatric patients who need intravenous fluid therapy Whyte 2009; Wilson 2009). During anaesthesia, Whyte (2009) suggest that anaesthetic practitioners should closely monitor the patient’s volume and composition of glucose and electrolyte tonicity. This is needs to be considered in relation to subclinical dehydration that commonly occurs during the perioperative period. Guidelines proposed by the National Patient Safety Agency (2007) in the UK suggest that paediatric patients should be monitored for electrolytes at minimum intervals of 24 hours. When conducting volume resuscitation, Whyte (2009) suggests that anaesthetic practitioners should use isotonic fluid. This needs to be considered in relation to replacing continuous non-hemorrhagic fluids. Whyte (2009) also suggests that practitioners should observe symptoms of hyponatremia that commonly occur in paediatric due difference in children brain and skull volumes. For minor surgeries, paediatric patients do not require intravenous fluids preoperatively; hence anaesthetists should ensure that the patients do not feed on anything for the shortest time possible (Benson et al. 2010). This helps to minimise discomfort brought about by thirst and hunger. Paediatric fluid is administered for three main reasons: replacement and maintenance of continuous losses and resuscitation (Wilson 2009). During the induction of anaesthesia, Whyte (2009) suggests that anaesthetic practitioners should make sure that the patient has an adequate electrolyte circulation. If a dehydration or hypovolaemia is noted, isotonic solution or blood additives are used to correct the situation (Benson et al. 2010). However anaesthetics should be very careful in administering intravenous fluids as speedy concentration of hypotonic fluids may cause hyponatraemia (NPSA, 2007). The process of monitoring fluids should be continued until the child is ably to take enough amounts orally (Wilson, 2009). Therefore, paediatricians should ensure that they measure and replace ongoing losses during the postoperative period. Stacy and Lough (2014), revealed that to manage decreased levels of temperature in paediatric patients, anaesthetic technicians should simultaneously; discontinue the use of the anaesthetic agent, conduct hyperventilation with complete concentrations of oxygen, restore acid base balance, use required medication to treat dysrhythmias, and loosen up contractions of skeletal muscles. Benson et al. (2010) mentioned that dantrolene sodium should be administered immediately to provide therapeutic blood levels in order to maintain thermal regulations after a surgical procedure. Further, Groner et al. (2000) revealed that anaesthetics should offer clinical procedures that include; regulation of environmental factors, provision of physical comfort to patients during interventions, supporting the thermoregulatory process, and providing physiology stability. c. Surgical Intervention A number of articles have recommended the importance of preoperative fasting in preventing pulmonary aspiration of stomach contents and preventing a rise in gastric conditions during Anaesthesia (Maltby 2006; Benson et al. 2010). The occurrence of aspiration has significant effects to a patient and may lead to Mendelson’s syndrome. This syndrome is caused by increased level of acidity in gastric contents. For effective management, Homles et al. (2011) suggest airway adjuncts should be used to secure the airway, and in turn reduce the likely incidence of perioperative aspiration. Accumulating evidence suggest that clearing gastric fluids up to two hours before paediatric surgery promotes gastric emptying by decreasing volume and acidity of stomach contents (Rang et al. 2005). According to Park and Serrano (2003), aspiration can also be triggered by emergency surgeries, difficult airways and inadequate anaesthesia. Therefore, to avoid fatal cases, patients should observe starving for the maximum number of hours. According to Fleisher (2009), preoperative surgical interventions must be observed in surgical operations. Czzin and Blanchard (2011) suggested that paediatricians should use pharmacological agents such as antacids, antisecretory agents and surface barriers to neutralizes acid present in the stomach and reduce damage caused by pulmonary aspiration. Benson et al. (2010) noted that water increases in children than in adults as a result; the preoperative period may affect fluid balance. Intake of clear fluids two hours before surgery reduced rates of pulmonary aspiration. Perioperative guidelines devised by the RCN suggest that children above the age of 6 years should abstain from intake of solid foods 4 hours prior to operation and clear liquids 2 hours (RCN 2005). According to Kaplan et al. (2001), bleeding is an important aspect to be considered in surgical interventions. Persistent bleeding may result from inadequate homeostasis, arteries and coagulation, and anaesthetics need to be ready to handle such cases (Kaplan et al. 2001). Anaesthetics should make sure that they maintain balanced thermal regulation prior, in progress and after an operation. In cases where there is excessive bleeding, blood expanders like crystalloid solutions are administered to compensate lost blood. Sutures and staples also close the incision and stop bleeding (Kaplan et al. 2001). d. Pain Management Studies conducted by Paul and Serrano (2003) indicate that sufficient pain relievers should be provided to paediatric patients. Elliott and Smith (2010) believe that the relief of pain is a right to all paediatric surgeries. Eliot and Smith (2010) also believe that proper management of pain during and after surgery decrease physiological stress and chances of chronic pain to patients. The analgesic pain bladder, according to (Leaper and Whitaker 2010) should also be used to measure the intensity of pain in paediatric patients who are unable to express themselves. According to Benson et al (2010), effective pain management in paediatric cases uses a stimulus to sensitize body systems that in turn reduce pain. (Miller 2010) discuses the pre-emptive method heavily reduces acute pain. The regular pre-emptive methods used comprise epidural nerve blocks or neuralgia blockade (Brill et al, 2003). Leaper and Whitaker (2010) also note that nitrous oxide and electrical stimulation of nerves can be used to relieve acute pains. Legasse (2002) emphasizes that anaesthetists should use the pain management ladder when administering analgesia to paediatric patients. This needs to be considered in relation to the increasing effects of drugs and addiction to pain relievers. During the postoperative period, Miller (2010) suggests that anaesthetic practitioners should reduce analgesia and the routes of administration tailored to suit patients. Pain can also be alleviated using non-pharmacological methods. Thompson (2010) suggests that the hospital environment may act as a distress and cause more pain to the child. To achieve this, a conducive hospital environment with minimal people visiting the child should be encouraged and parents should be involved in the care. The Physiological Care of Children in Hospital According to the Royal College of Nursing report on core competences for nursing children, paediatric patients have psychological and physiological needs that should be met by a child-friendly hospital environment and staffed by trained nurses (2012b). A similar report (RCN 2013), also reveal that patients in paediatric units heavily depend on health care from nurses. Rushforth (2008) believes that high the dependency tool and nurse-to-patient ratios should be applied in most clinical settings. Standards set by the Royal College of Nursing (2007) propose higher qualifications for anaesthetists working in paediatric high dependency units. Training should also incorporate elements to assist the recognition of depreciating health in a child (RCN, 2007). RNC also recommends the use of workforce that ensures that staffing meets the “requirements the children requiring high dependency care”. Rushforth (2008) also believes that hospitals should develop methodologies that separate paediatric patients according to ages and intensity of illness. According to (Thomas 2009), creating a child interactive hospital atmosphere is among the best environmental interventions used to create conductive environments for children. Play is a recreational therapy that not only helps in healing of the children but also creates an environment where therapists can interact with the children through informal ways (Thomas 2009). According to a report released by the Royal College of Nursing about core competences for nursing children and young people (2012b) the use of play by paediatricians creates emotional control in children through creative thinking. Recreational therapy includes activities that engage children in play (Thomas 2009) and other recreational activities that promote their growth. Other studies (Kennelly and Brien-Elliot 2001) illustrated the introduction of other programs like gardens, pet therapy and camps. Thomas (2007) believe that recreational therapy does not limit itself to play but also important elements like allowing adequate visiting hours for parents, guardians and loved ones, allowing school aged children to continue with homework in the wards and helping children at meals time to accept food when necessary. A number of theories explain the developmental structured of children in a hospital setting. Researchers (Siegler 1998; Thomas 2009) have adopted the use of cognitive, social learning and attachment theories to explain behavioural and cognitive development of paediatrics patients. Cognitive theories are mainly concerned with how children learn information and what they learn (Thomas 2009). Siegler (1998) believes that the theory of cognition equips paediatrics specialists with observational tactics where they can note and learn behavioural patterns. This includes the manipulation and generation of new ideas through the creation of informal communication. According to Thomas (2009), communication is an integral part paediatrics care, and it be used together with other medical treatments. In addition, temperamental theories provide a prospective outlook at patients’ agents of socialization offers individualized, systemic or ecological overviews of a patients’ social support group (Thomas 2009, pp. 18). Through this theory, paediatricians study families and develop a reflection on the need to support the child outside a clinical setting. Legal and Ethical Issues In carrying out their duties professionally, anaesthetists must protect and safeguard the health and welfare of vulnerable people including children. A report by the association of paediatric anaesthetics indicates that, anaesthetists are supposed to take action in cases where they suspect maltreatment and neglect of paediatric patients (RCN, 2007). The RCPCH also provides that, anaesthetics should act as links between child protection units and anaesthetic units in hospitals, and have a duty to ensure that issues related to safeguarding paediatrics are communicated effectively. This study is developed from a case study whereby a six year old boy is taken to the hospital by the mother’s boyfriend. The case presents a contradictory situation as regards the issue of consent for anaesthetics to be conducted during the surgery. It is clear that the adult who has brought the child to the hospital is the mother’s boyfriend. Therefore, the legal responsibilities towards to the child are not well established. A background check of the nature of relationship between the mother’s boyfriend and the child is not established. In addition, medical practitioners are not aware of the mother’s responsibility and whereabouts. In this case, ethical and legal issues regarding consent to conduct medical procedures on the child arise because of their inability to make logical decisions as the doubtfulness of the adult figure to give consent. According to (Gwinnutt 2008), legal consent on all medical procedures and examination under general anaesthesia must be obtained from adults or individuals who have direct responsibility for the child. The British Medical Association prerequisite on paediatric anaesthesia is that, parental consent must be sought for children who are below 16 years of age. In addition, the report on Child Protection/Safeguarding (2007) provides that anaesthetics do not require consent in examining a paediatric patient if there abuse or neglect is suspected. According to McLean and Mason (2009), practitioners should examine paediatric patients and record relevant information in line with their ethical obligations of safeguarding the health and interests of the public. In paediatric cases where consent is not granted in undertaking specific medical examinations that are deemed necessary and important for a child or no parental consent can be sought, the Royal College report on Lead anaesthetists for Child Protection/Safeguarding (2007) require that, consultation be made immediately with the trust’s legal advisors. In anaesthetics, the safety of the child takes priority over all other duties. According to the RCoA, anaesthetics should be familiar with the children act, child protection issues, children rights and procedures of obtaining consent (RCoA 2007). RCPH sets standards regarding the safeguarding of children that require anaesthetics to respect the rights of children as pertains protection from harm and the right to confidentiality (RCPH 2007). Therefore, may be required to detain children in healthcare centers in cases that require a physical examination for evidence. In cases of child reported abuse, children are to be listened to and personnel should not press for information. If anaesthetics are positive of abuse in children, they are advised to consult with personnel specializing in children protection as well as seek counsel from the lead anaesthetic officer. Bibliography Allen, L., Englelhardt, T., and Lendrum, R. 2013. Do not know where to press? Cricoid pressure in the very young. European Journal of Anaesthesiology, 30: 1-2. Benson et al. 2010. Children’s Orthopaedics and Fractures. London: Springer Verlag London Limited Brill, S., Gurman, G., and Fisher, A. 2003. 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Retrieved on March 18, 2014 from http://www.frca.co.uk/article.aspx?articleid=100481 Whyte, S. 2009. Perioperative fluid and electrolyte balance in children. Anaesthesia & intensive care medicine, 10, 2: 93-97 Yentis et al 2009 Anaesthesia and Intensive Care A to Z: an encyclopaedia of principles and practice 4th ed. New York: Elsevier. Read More