Manual detorsion under sedation and <scp>POCUS</scp>

Manual detorsion performed by a paediatric emergency physician under POCUS guidance and nitrous oxide analgesia can rapidly and safely alleviate pain and prevent further ischemic change to a torsed testis. Testicular survival is determined largely by the duration and extent of ischemia to the affected testis. European Association of Urology guidelines state that manual detorsion should be attempted in all paediatric patients.1 However, manual detorsion is infrequently performed in paediatric emergency medicine. We present a case of testicular torsion diagnosed on point of care ultrasound (POCUS) and manually detorsed by a paediatric emergency physician under nitrous oxide and POCUS guidance. A 15-year-old presented with 3 h of right scrotal pain. Examination showed a hard, tender right testis with intact cremasteric reflex. POCUS showed edematous parenchymal change with lack of blood flow, and a small hydrocele (Fig. 1). A whirlpool shaped cord complex was appreciated, confirming torsion (Fig. 2). Urology was notified, but all operating rooms were in use. With patient and parental consent, and over an hour after POCUS diagnosis, the paediatric emergency physician performed manual detorsion with a single rotation in the medial to lateral direction under nitrous oxide analgesia. Normal arterial flow (Figs 3, 4) was demonstrated on repeat POCUS, as was absence of cord complex (Video S1). He reported an immediate decrease in pain, and within several minutes an absence of pain. POCUS immediately and 35 min after detorsion showed blood flow to the testis (Video S2). The patient underwent radiology performed ultrasound that evening and again the following morning, both unremarkable. Orchiopexy was performed on hospital Day 1. Scrotal POCUS performed by paediatric emergency physicians has high accuracy for the diagnosis of torsion, and can be available prior to radiology performed ultrasound.2 Fentanyl analgesia and propofol sedation have both been described in PED manual detorsion,3, 4 as has POCUS guided detorsion.5 Our case is the first report of manual detorsion under POCUS guidance and nitrous oxide, and took only minutes to perform. POCUS before and after detorsion was immediately available and caused negligible delay. In our case, we used inhaled nitrous oxide for analgesia and mild sedation. To prevent higher concentrations of nitrous from causing deep sedation, we recommend mask delivery for children who are able to hold the mask on their own. Deeper levels of sedation will cause the mask to fall, and the child to quickly recover. Younger children can receive nitrous oxide via a nasal mask, which allows entrained room air to enter from the mouth.6 Additional sedoanalgesia, such as fentanyl for pain7 or midazolam for mask acceptance, can be added via nasal atomizer but may result in deeper sedation than would be expected at a given percentage of nitrous oxide. A younger or less cooperative child may not be able to undergo detorsion without deep sedation. However, deep sedation may interfere with the physician's ability to assess pain relief and thereby monitor progress in the reduction. The risk of causing torsion by rotating a normal testis has never been reported, and injury to ischemic tissue from a bedside detorsion manoeuvre in the direction of the torsion is theoretically possible but has also not been reported. Orchiopexy should be performed even if manual detorsion is performed successfully, as there is risk of residual incomplete torsion or recurrence of torsion. Manual detorsion performed by a paediatric emergency physician under POCUS guidance and nitrous oxide analgesia can rapidly and safely alleviate pain and prevent further ischemic change to a torsed testis. Video S1: Structures proximal to the testis demonstrating absence of whirlpool sign. Video S2: Testis half an hour after detorsion demonstrating return of flow. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.