20.3 Primary Care Procedures & Life-Threatening First Response

Domain III.C is procedures and life-threatening interventions. The May 2023 CPNP-PC outline names ten office procedures. Teach all ten: indication, the principle of the technique, and when you do not do this in a primary-care room. The same domain wants you to initiate anaphylaxis care, airway support, CPR awareness, septic-shock transfer, status epilepticus response, and hemorrhage control — then move the child. You are not staffing a PICU.

Quick Answer: Reduce a classic nursemaid's elbow in the office. Stain a painful eye with fluorescein under cobalt-blue light. Apply fluoride varnish. Drain a simple fluctuant abscess. Remove visible ear or nose foreign bodies that are not disk batteries. Cauterize an umbilical granuloma with silver nitrate after you protect the skin. Do not fish out a button battery, an airway foreign body, or a deep abscess next to the eye or great vessels. For anaphylaxis, intramuscular epinephrine in the anterolateral thigh comes first, then EMS.

Clinic opening. A 2-year-old will not use the left arm after an adult yanked her away from a curb. The arm is slightly flexed and pronated. There is no swelling and no deformity. If you send every one of these to the ED for a radiograph before you attempt a reduction, you missed a named office procedure. If the same child has a swollen, tender elbow after a fall onto the arm, and you keep twisting it, you also missed III.C — that one is not a nursemaid's.

The ten named procedures — indication, principle, stop rules

Cerumen removal. Indicate it when you cannot see the tympanic membrane, when wax is causing discomfort or a hearing complaint, or when you need a clean canal to finish the exam. Principle: visualize, then a curette under direct view, or irrigation with body-temperature water only if the TM is intact and there are no tubes. Soften hard wax first when you can. Stop if you meet a foreign body, a disk battery, a perforated TM, tympanostomy tubes, or a fight that will lacerate the canal. Irrigation of a bean or other vegetable matter swells the object — that is an ENT problem, not more water.

Collect skin and body-fluid specimens. This is a named procedure because technique decides whether the lab result is usable. Wound culture comes from the unroofed pustule or abscess cavity, not a dry crust. Throat swabs hit both tonsillar pillars and the posterior pharynx. KOH scrapings come from the active scale border. Infant urine that will drive antibiotics is a catheterized (or SPA) sample, not a bag stuck on for convenience. If the specimen is forensic (acute sexual assault), you collect only what your protocol and the receiving CAC or ED need; you do not freelance a kit and break chain of custody.

Fluorescein staining. Chapter 18.3 is where you read the pattern. Here is the procedure: moisten a strip, touch the inferior conjunctiva, blink, view with cobalt-blue light, irrigate extra dye, document. Linear uptake after a fingernail is a corneal abrasion. Branching dendritic uptake is HSV keratitis — ophthalmology now, no topical steroid. A contact-lens wearer with a dense infiltrate is an ulcer until proven otherwise. Do not fluorescein and press on a suspected open globe; shield and send. Do not dispense topical anesthetic for home — it delays healing and lets the child keep injuring the cornea.

Fluoride application. Once teeth are present, varnish in the medical home, commonly every 3–6 months, including children who already drink fluoridated water. Dry the teeth, apply a thin film, and coach a soft diet for a short interval and no brushing until later the same day per the product. Varnish is prevention you control today; it is not a dentist-only luxury. Chapter 5.3 is the remineralization science. This section is: you actually apply it.

Incision and drainage. Indicate for a simple, fluctuant, superficial abscess in a nontoxic child after analgesia (and procedural support that matches the child's age). Principle: incision over the point of fluctuance, drain, culture the pus, consider a loop drain or brief packing, warm soaks, follow-up. Stop and transfer for periorbital collections, deep neck space, abscesses abutting major neurovascular structures, a toxic or immunocompromised child, or a prepubertal labial abscess — the last is anatomy plus a maltreatment question, not a quick clinic lance.

Reduction of nursemaid's elbow. Classic: axial traction on a pronated forearm (yanked from a curb, swung by the hands). The annular ligament slips over the radial head. The child will not use the arm, holds it slightly flexed and pronated, and is not swollen. If classic, no radiograph is required. Reduce with hyperpronation (often more successful on the first try) or supination-flexion. A click and return of use in minutes is success. If there is deformity, swelling, point tenderness, a fall on an outstretched hand, or failure after appropriate attempts, stop. Image. Do not keep reducing a supracondylar fracture.

Removal of foreign body. Visible bead in the nose of a cooperative preschooler: good light, stable restraint, forceps or a curved hook, or a parent's kiss technique for some nasal objects. Ear canal: visualize, then a curette or alligator forceps. Do not attempt office removal of a disk battery in the ear or nose — alkali injury is a clock, same family as esophageal batteries. Do not chase a suspected airway foreign body in clinic; that child needs a controlled airway in a hospital. Do not irrigate organic matter. If you cannot see it, cannot hold the child safely, or you make the object worse, ENT or ED.

Removal of sutures and staples. Indicate when the wound has reached the expected take-down day and is not infected. Principle: clean, cut under the knot, pull toward the incision so you do not reopen it, count what you remove, consider adhesive strips. Typical timing: face about 3–5 days, scalp about 5–7, trunk and arms about 7–10, joints and legs about 10–14. Do not yank sutures out of a red, draining wound and call it done — treat the infection and protect the closure. Buried absorbable suture that you cannot see is not a fishing expedition.

Umbilical cord cauterization. After the cord separates, a small moist pink granuloma in a well infant is the indication. Principle: silver nitrate applied briefly to the granuloma. Protect surrounding skin with petroleum jelly; silver nitrate on intact abdominal skin is a chemical burn, which is the classic procedure complication. Do not cauterize omphalitis (periumbilical erythema, purulence, fever, ill infant) — that is infection, often ED and parenteral antibiotics. Do not cauterize a large moist lesion that leaks urine or stool; think patent urachus or omphalomesenteric remnant and refer. Reassess: granulomas sometimes need more than one careful application.

Wart removal. HPV. Salicylic acid with occlusion is first-line home therapy for many common warts. Office cryotherapy (liquid nitrogen freeze-thaw) and, for selected filiform lesions, snip or curettage are the destruction methods you should be able to discuss. Recurrence is common; do not promise a one-freeze cure. Anogenital warts in a young child are a maltreatment-consideration visit (20.1), not a silent freeze. Do not destroy a lesion you have not diagnosed — a pigmented lesion is not a wart because a caregiver asked you to freeze it.

Life-threatening first response — initiate, then transfer

The outline pairs procedures with life-threatening interventions. Your job is the first right move and the ambulance, not a homemade ICU.

• Anaphylaxis. Intramuscular epinephrine in the anterolateral thigh first — not diphenhydramine, not a steroid delay. Typical autoinjector teaching: 0.15 mg in the young-child weight band, 0.3 mg at about ≥30 kg, matching the device the family carries. Airway position, oxygen if you have it, call EMS. Observation for biphasic reaction is a hospital problem. Chapter 11.1 is the allergy plan; this is the office first minute.
• Airway. Position, suction, age-appropriate foreign-body maneuvers if the obstruction is witnessed and complete. No blind finger sweep. A deteriorating airway leaves the clinic with EMS, not with you "watching one more minute."
• Unresponsive infant CPR awareness. Start compressions, use the current BLS ratio you are certified in (single-rescuer 30:2 is the usual community teaching; two-rescuer infant/child 15:2), rate 100–120, and get an AED/EMS. You are not running a code for an hour in an office hallway.
• Septic shock. Recognize (altered perfusion, tachycardia, fever or hypothermia). Give oxygen, obtain access if you can without delaying transport, and move to the ED. Goal-directed PICU fluids and pressors are not a clinic protocol you invent.
• Status epilepticus. Protect the airway, time the seizure, give a benzodiazepine if your office has a protocol and a legal stock (intranasal midazolam or rectal diazepam are the community forms). Then EMS. Do not drive the convulsing child yourself.
• Hemorrhage. Direct pressure. A catastrophic extremity bleed may need a tourniquet. Then EMS. You do not explore a bleeding neck wound in a procedure room.

Initiate then transfer. The primary-care CPNP-PC does not run a PICU, does not sit on a button battery "to see if it moves," and does not I&D what sits next to the globe. That restraint is the procedure skill as much as the reduction click.

Clinic close. Walk into the room with the ten-item list in your head. Classic nursemaid's, varnish, fluorescein, simple abscess, visible non-battery FB, granuloma with protected skin: clinic. Battery, airway, deep or vital-structure abscess, omphalitis, anaphylaxis, status, shock: first response and out the door.