Thread by @AnnYoungMD

Wanted to share a few tips for positioning for toddler facial laceration repair, inspired by @TessaRDavis great tweetorial on positioning for PIVs. I hope this inspires a thoughtful preparation for your next toddler lac repair!
#PEMTwitter #FOAMed
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1. Toddler position: When possible, avoid tightly "swaddling" (it makes them distressed/hot) or the child sitting on a parent (2 moving targets). I prefer the toddler supine watching a tablet held above their head (change tablet position to get more/less neck extension).
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A neck roll can prevent unwanted neck extension for forehead/cheek lacerations. Conversely, a shoulder roll gets more extension for better chin exposure. This photo demonstrates neck over extension, which is bad for airway management, but good for fixing a chin lac!
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2. Your position: I like to sit and "mime" my suture throws before starting. This is when I may change the side of the bed I will be on and adjust the bed/stool height, overhead lamp, and procedure trays.
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During miming, I insure that my forearms/wrist have somewhere to rest, as when the child moves (they will), I have to be able to move with them. It's a synchronized dance where the child is the lead!

3. Holder position: Have your holder use a flat palm anteriorly on each of the child's shoulders to prevent sitting up, while the holders' forearms are on either side of the child's head to prevent lateral movements. It almost looks like holding c-spine precautions.
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This hold can be modified depending on patient movement. If there's too much movement and the holder can't hold the shoulders down, I'll ask a parent to take over the shoulders and let the holder focus on the head only.
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I also ask my holder if they are comfortable. If they're not comfortable, your hold will not be optimized. Sometimes this means getting them a stool to stand on, adjusting the bed height, or removing the handles at the head of the bed so they can get closer to the bed.
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4. Parent position: I always give the parents a job to do: holding the video above the child's head, holding the child's hand or shoulders/arms, or talking/singing to the child. This helps parents be helpful and occupied while I work.
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5. Keep them dry! This isn't a positioning tip, but it goes a long way to keeping toddlers happy. Toddlers don't like water spraying into their eyes, ears, or neck, so irrigate using a splash guard, protect child's eyes w/your hand (or Tegaderm), & towels/chux over ears/neck.
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That's it! I hope these tips are helpful and make your next toddler facial laceration repair more successful and comfortable for everyone involved.
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