• 
• 

Three Part Question

In [children requiring wound suturing in the ED] is [topical lidocaine adrenaline tetracaine gel effective] at [reducing the need for admission for wound closure/general anaesthesia]

Clinical Scenario

You are assessing a wound on the forearm of a 4 year old boy who fell whilst playing football. There does not appear to be any deeper structure involvement but you feel the wound is likely to require suturing.

Your department does not currently perform paediatric sedation and therefore the vast majority of young children presenting with wounds requiring suturing are referred to specialty teams for general anaesthetic for wound closure.

You have worked in a department where topical anaesthetic is applied to wounds in children to facilitate closure and wonder whether the use of this in your department would reduce the number of children referred for closure under general anaesthetic.

Search Strategy

Embase to February week 2 2013 and
Ovid Medline to February Week 2 2013



EMBASE

(lat AND gel).ti,ab; OR (lidocaine AND adrenaline AND tetracaine AND gel).ti,ab; OR (lidocaine AND epinephrine AND tetracaine AND gel).ti,ab; OR (tetracaine AND adrenaline AND lidocaine).ti,ab; OR(lidocaine AND epinephrine AND tetracaine).ti,ab;
AND
(wound AND closure).ti,ab; OR (wound AND management).ti,ab; OR sutur*.ti,ab; OR wound.ti,ab; OR stitch*.ti,ab;
Limit to: (Human Age Groups Child unspecified age)

Medline

(exp Lidocaine/ OR lignocaine.mp.
AND exp Epinephrine/ OR adrenaline.mp.
AND exp Tetracaine/
AND exp Administration, Topical/)
OR lat gel.mp. OR let gel.mp. OR lidocaine adrenaline tetracaine.mp. OR lidocaine epinephrine tetracaine.mp. OR lignocaine adrenaline tetracaine.mp OR lignocaine epinephrine tetracaine.mp.
AND
exp \\\\\\\\\\\\\\\"Wounds and Injuries\\\\\\\\\\\\\\\"/ OR exp Sutures/
limit to \\\\\\\\\\\\\\\"all child (0 to 18 years)\\\\\\\\\\\\\\\"

Search Outcome

19 results from Embase
26 results from Medline

1 paper relevant to 3 part question (same paper identified by both searches)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
O\'Connor G & Mullarkey C 2010 Ireland	397 children aged ≤14yrs presenting to ED with a wound	Retrospective case review Comparison of rates of referral and rates of GA requirement for wound closure pre and post introduction of LAT gel (4% lidocaine, 1:1000 adrenaline, 0.5% tetracaine) to ED (4% lidocaine, 1:1000 adrenaline, 0.5% tetracaine) applied to wound 20 mins prior to wound closure	Referral to speciality team	39 pre LAT gel, 19 post LAT gel	Small numbers Restrospective therefore unable to comment on factors not documented in notes at time of patient treatment
			Requirement for general anaesthetic	31 pre LAT gel, 15 post LAT gel. p=0.018

Comment(s)

Wound suturing in children can be a stressful experience for patient, parent and physician Departmental sedation has not yet been adopted by all EDs, and the time and staff required may not always be available in those that have The use of topical anaesthetic solutions have been shown to reduce both the pain of local anaesthesia and the need for it (Anderson K. and Jenner R. 2012) LAT gel has been shown to be as efficacious as the more traditionally used TAC gel, with a superior safety profile (Adler A.J., Dubinske I. & Eisen J 1998) There is limited evidence available on the ability of topical anaesthesia to reduce specialty referrals and/or GA for wound closure - this study aims to answer this question

Clinical Bottom Line

The use of LAT gel for the closure of wounds in children may reduce the requirement for specialty referral and ultimately general anaesthetic (and the associated risks) for wound closure However, the evidence is limited and further studies (ideally prospective) are required. References O\\\\\\\'Connor G, Mullarkey C. Topical anaesthesia in children: reducing the need for specialty referral. 2010. European Journal of Emergency Medicine 17(2):97-100. Anderson K. & Jenner R. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary BET 1: Comparison of Topical Anaesthetic Agents for Minor Wound Closure in Children. Emergency Medicine Journal 29(4):339-40. Adler A.J., Dubinisky I. & Eisen J. Does the use of topical lidocaine, epinephrine and tetracaine solution provide sufficient anaesthesia for laceration repair? 1998. Academic Emergency Medicine 5:108-112

References

1. O\'Connor G, Mullarkey C Topical anaesthesia in children: reducing the need for specialty referral European Journal of Emergency Medicine 2010; 17(2):97-100