Paediatric Acute care Guidelines PMH Emergency Department

Background

  • A painful and anxiety-provoking complaint which can occur in the process of zipping or unzipping trousers
  • It is most commonly seen in pre-school and early school age boys
  • There has often been a pre-hospital attempt to free the entrapped tissues, which may have been distressing
  • As this is a relatively rare form of trauma, it is worth seeking the assistance of a colleague in the department who has had experience with a similar injury to enable help with management
  • It is important to be sensitive, especially with adolescents
    • It may be preferable to have male medical/nursing staff involved if possible 
There are two patterns of entrapment seen and the genital tissue may be:
  1. Entrapped in the mobile zipper head
  2. Caught between the interlocking teeth of the zipper

Assessment

Management

Preparation 

  • Keep the child in their most comfortable position (e.g. parents lap or supine on the bed) 
  • An explanation of the procedure along with reassurance and a gentle approach will help to gain a compliant patient 
  • Sedation and Pain management
    • Analgesia is vitally important and should be given early
    • Inhaled nitrous oxide may be useful with aiding the removal procedure
    • Conscious sedation may be necessary to the distressed and anxious child
  • Local Anaesthetic
    • EMLA® topical anaesthetic applied for a period of time to numb the affected area.
  • Dorsal Penile Block
    • Some centres have advocated local infiltrate of lignocaine (never use adrenaline with this) but this is usually only required for significant skin or tissue entrapment (usually unnecessary) 
  • Mineral oil (lubricant) applied to the affected area for 10 minutes may assist to free the penile tissue when gentle traction is applied.
  • It may be necessary to cut closely around the zipper so the rest of the trousers/jeans are no longer in the way. This must take place if the zip is to be cut through without causing any unnecessary traction on the exquisitely painful tissues. 

Extraction Manoeuvers

1. Entrapped in the mobile zipper head: 
  • Use wire cutters to cut through the median bar of the zipper fastener
  • The front and back plates will then fall apart and allow the skin to be freed
2. Caught between the interlocking teeth of the zipper
  • If the skin is caught below the zip as shown in the diagram below – cut across the zip at point 2 (inferior to the entrapment site) to enable the two interlocking rows of the teeth to be gently pulled apart freeing the skin 
  • If the zip is still entangled in the skin it will be necessary to pull the zip up forcefully to create the situation in 1 

Post Removal 

  • Ensure there has been no significant damage to the penile meatus
  • Other small lacerations or bruises usually heal very well
  • Significant injuries to the tissues should have surgical review 

Nursing

Routine nursing care.

References

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