▶BY PERI-ARTICULAR INJECTION
▶Child 12–17 years: 10 – 20 mg, according to size of the
joint, no more than 2 joints should be treated on any
one day
Juvenile idiopathic arthritis
▶BY INTRA-ARTICULAR INJECTION
▶Child 3–11 years:(consult product literature)lCONTRA-INDICATIONSAvoid injections containing benzyl
alcohol in neonates.consult product literature
lCAUTIONSConsult product literature
lINTERACTIONS→Appendix 1 : corticosteroids
lSIDE-EFFECTSProtein catabolism.skin fragility
lPRESCRIBING AND DISPENSING INFORMATIONVarious
strengths available from’special order’manufacturers or
specialist importing companies.
lNATIONAL FUNDING/ACCESS DECISIONS
All Wales Medicines Strategy Group (AWMSG) Decisions
TheAll Wales Medicines Strategy Grouphas advised
(August 2017 ) that triamcinolone hexacetonide 20 mg/mL
suspension for injection is recommended as an option for
use within NHS Wales for the treatment of juvenile
idiopathic arthritis.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Suspension for injection
EXCIPIENTS:May contain Benzyl alcohol
▶Triamcinolone hexacetonide (Non-proprietary)
Triamcinolone hexacetonide 20 mg per 1 mlTriamcinolone
hexacetonide 20 mg/ 1 ml suspension for injection ampoules|
10 ampouleP£ 120. 00
4.2 Soft tissue disorders
Soft-tissue disorders
Soft-tissue and musculoskeletal disorders
The management of children with soft-tissue injuries and
strains, and musculoskeletal disorders, may include
temporary rest together with the local application of heat or
cold, local massage and physiotherapy. For pain relief,
paracetamol p. 271 is often adequate and should be used
first. Alternatively, the lowest effective dose of aNSAID(e.g.
ibuprofen p. 655 ) can be used. If pain relief with either drug
is inadequate, both paracetamol (in a full dose appropriate
for the child) and a low dose of a NSAID may be required.
Extravasation
Local guidelines for the management of extravasation
should be followed where they exist or specialist advice
sought.
Extravasation injury follows leakage of drugs or
intravenousfluids from the veins or inadvertent
administration into the subcutaneous or subdermal tissue. It
must be dealt withpromptlyto prevent tissue necrosis.
Acidic or alkaline preparations and those with an
osmolarity greater than that of plasma can cause
extravasation injury; excipients including alcohol and
polyethylene glycol have also been implicated. Cytotoxic
drugs commonly cause extravasation injury. Very young
children are at increased risk. Those receiving anticoagulants
are more likely to lose blood into surrounding tissues if
extravasation occurs, while those receiving sedatives or
analgesics may not notice the early signs or symptoms of
extravasation.
Extravasation prevention
Precautions should be taken to avoid extravasation; ideally,
drugs likely to cause extravasation injury should be given
through a central line and children receiving repeated doses
of hazardous drugs peripherally should have the cannula
resited at regular intervals. Attention should be paid to the
manufacturers’recommendations for administration.
Placing a glyceryl trinitrate patch p. 135 or using glyceryl
trinitrate ointment distal to the cannula may improve the
patency of the vessel in children with small veins or in those
whose veins are prone to collapse. Children or their carers
should be asked to report any pain or burning at the site of
injection immediately.
Extravasation management
If extravasation is suspected the infusion should be stopped
immediately but the cannula should not be removed until
after an attempt has been made to aspirate the area (through
the cannula) in order to remove as much of the drug as
possible. Aspiration is sometimes possible if the
extravasation presents with a raised bleb or blister at the
injection site and is surrounded by hardened tissue, but it is
often unsuccessful if the tissue is soft or soggy.
Corticosteroidsare usually given to treat inflammation,
although there is little evidence to support their use in
extravasation. Hydrocortisone p. 440 or dexamethasone
p. 439 can be given either locally by subcutaneous injection
or intravenously at a site distant from the injury.
Antihistamines and analgesics may be required for symptom
relief.
The management of extravasation beyond these measures
is not well standardised and calls for specialist advice.
Treatment depends on the nature of the offending
substance; one approach is to localise and neutralise the
substance whereas another is to spread and dilute it. The
first method may be appropriate following extravasation of
vesicant drugs and involves administration of an antidote (if
available) and the application of cold compresses 3 – 4 times a
day (consult specialist literature for details of specific
antidotes). Spreading and diluting the offending substance
involves infiltrating the area with physiological saline,
applying warm compresses, elevating the affected limb, and
administering hyaluronidase below. A salineflush-out
technique (involvingflushing the subcutaneous tissue with
physiological saline) may be effective but requires specialist
advice. Hyaluronidase shouldnotbe administered following
extravasation of vesicant drugs (unless it is either specifically
indicated or used in the salineflush-out technique).Enzymes used in soft-tissue disorders
Hyaluronidase is used for the management of extravasation.ENZYMES
Hyaluronidase
lINDICATIONS AND DOSE
Extravasation
▶BY LOCAL INFILTRATION
▶Child:(consult product literature)lUNLICENSED USELicensed for use in children, but age
range not specified by the manufacturer.
lCONTRA-INDICATIONSAvoid sites where infection is
present.avoid sites where malignancy is present.do not
apply direct to cornea.not for anaesthesia in unexplained
premature labour.not for intravenous administration.not
to be used to enhance the absorption and dispersion of
dopamine and/or alpha-adrenoceptor agonists.not to be
used to reduce swelling of bites.not to be used to reduce
swelling of stingsBNFC 2018 – 2019 Soft tissue disorders 663
Musculoskeletal system10