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Three Part Question

In [children presenting with a minor skin laceration requiring suturing] is [topical anaesthetic as effective as lidocaine infiltration] in [reducing the pain and distress of wound closure.]

Clinical Scenario

A 7 year old boy presents with a scalp laceration that requires suturing for optimal wound closure. His mother tells you that he is scared of needles and is liable to become upset. You wonder if topical anaesthetic would be as effective as lidocaine infiltration in allowing pain-free wound closure.

Search Strategy

OVID interface on the world wide web. 1966 – December 2004
Cochrane database of systematic reviews Edition 4 2004
Medline: [Anesthetics, Local/ or Anesthesia, Local/ or Lidocaine/ or Bupivacaine/ or local anaesthetic.mp] OR [Administration, Topical/ or Anesthetics, Local/] AND [paediatric filter] LIMIT to human and english language and all child <0 to 18 years>
Cochrane: Laceration topical

Search Outcome

Medline: 46 papers of which 7 were relevant to this question.
Cochrane: 8 papers, none relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pryor, GJ et al, 1980, USA	158 patients presenting to the emergency department with minor lacerations. Topical TAC versus lidocaine infiltration for anaesthesia.	PRCT	Acceptibility of application of anaesthetic.	TAC was thought to be more acceptible in children under 17y(P<0.0001), no significant difference in adults.	Few baseline data about patient group. Some data presented in graph form or percentage values only with significance mentioned in accompanying text.
			Efficacy of anaesthesia in patients over 10y	In 10-17y patients TAC was effective in 82% and lidocaine in 83% (P=1). In patients over 17y TAC was effective in 86% and lidocaine in 92% (P=0.25)
			Time taken to repair wound	Significantly reduced in children less than 5y (P<0.005).
Hegenbarth MA et al, 1990, USA	467 patients aged 18y or younger presenting to an emergency department with minor lacerations requiring suturing. Wounds classified as head/scalp or trunk/extremity then randomised to either topical TAC or lidocaine infiltration.	PRCT	Adequacy of anaesthesia for scalp/ head wounds	TAC adequate in 80.7%, lidocaine adequate in 86.6%.(P=0.159)	Randomised by case note number. Error in P value for adequacy of anaesthesia for scalp/head wounds. Only 68% of patients followed up when looking at wound infection rates though drop out rate similar in each group (68% of TAC patients, 66% of lidocaine patients reviewed).
			Adequacy of anaesthesia for extremity/trunk wounds	TAC adequate in 43.2%, lidocaine adequate in 89.4%.(P<0.0001)
			Infection rates	2.2% for both TAC and lidocaine groups.
Anderson, AB et al, 1990, USA	151 children under 18y presenting to the emergency department with skin lacerations less than 5cm. Intradermal lidocaine versus topical TAC versus topical placebo (adrenaline plus normal saline).	PRCT	Initial anaesthesia (tested by pinprick)	TAC 89% Lidocaine 79% Placebo 17% (TAC vs. placebo P<0.0001, Lidocaine vs. placebo P<0.0001)	Method of randomisation not clear from text. One error noted in results table. Some data only given in chart form.
			Pts requiring additional lidocaine infiltration	TAC 18% Lidocaine 23% Placebo 60% (TAC vs. placebo P<0.0001, Lidocaine vs. placebo P<0.0005)
			Complete pt compliance - assessed by physician	TAC 80% Lidocaine 49% Placebo 43% (TAC significantly better than either lidocaine or placebo P<0.002)
Kendall, JM et al, 1996, UK	107 children between 3-16y presenting to the emergency department with wounds less than 4cm requiring suturing.	PRCT	Pain score on application of anaesthetic	Infiltration of lidocaine significantly more painful than applicaiotn of TAC (P<0.001)	No mention of wound site. No breakdown of different age groups of children.
			Pain score on wound closure	No significant difference between lidocaine and TAC
			Acceptibility of procedure	14.5% of parents found procedure with AC gel
Smith, GA et al, 1996, USA	240 patients over 2y old presenting to the emergency department with a skin laceration 5cm or less that requires suturing. Bupivacaine with NA vs. etidocaine with NA vs. mepivacaine with NA vs. prilocaine with NA vs. TAC vs. lidocaine infiltration.	Partially blinded PRCT	Anaesthesia by pain score by patients, parents, suture technicians and research assistant observers	No significant difference between TAC, bupivacaine with NA and lidocaine infiltration. All other agents less effective.	The method of randomisation is described as block randomisation but there are 60 patients in both the lidocaine and TAC groups with 30 patients in each of the other groups. It is mentioned in the results area that some patients required supplemental lidocaine infiltration but does not say who or how this affected the outcome. Raw data is not provided, only the statistical methods and results of significance.
Ernst, AA et al, 1997, USA	66 patients aged 5y or over with lacerations <10cm Topical LAT gel vs. injectable buffered lidocaine with adrenaline	PRCT	Pain of anaesthetic application	LAT gel significantly less painful than lidocaine injection(P<0.001)(Mean VAS by physician for LAT=0 and Lidocaine=1.4. Mean VAS for patient - LAT = 0, Lidocaine = 1.2)	Small study. Data in figures poorly labelled.
			Pain of suturing	No significant difference between lidocaine and LAT gel. (For physician P=0.83, for patient P=0.48)
Smith, GA et al, 1997, USA	71 patients 2y or over presenting to the emergency department with a laceration on the face or scalp less than 5cm that required suturing. Topical TAC vs. topical mepivacaine and norepinephrine vs. lidocaine infiltration	PRCT	Effective anaesthesia by Visual Analogue Scale as judged by suture technician and research assistant.	No significant difference between effect of TAC and lidocaine infiltration. Mepivacaine less effective.(P=0.003 and P=0.0003 respectively)	Small numbers. Results provided in graph form.

Comment(s)

Application of topical anaesthetic for minor skin lacerations is significantly less painful than infiltration of local anaesthetic. The anaesthetic effect produced appears to be similar, particularly for face or scalp wounds. In addition topical anaesthetic will not cause tissue distorsion due to injection. The possibility of improved compliance plus the reduced use of needles will decrease the risk of needle-stick injury. Topical agents that do not include cocaine are cheaper, do not involve the rigmarole of dealing with a controlled drug and may be safer to use in children. All of the studies excluded wounds involving mucous membranes or poorly vascularised areas and extremities. There were no adverse effects in any of the listed papers that could be attributed directly to cocaine use though serious consequences have been documented in published case reports. The use of a topical agent in a gel form rather than a liquid may reduce some of the associated risks.

Clinical Bottom Line

Topical anaesthetics should be used on selected minor lacerations in children as they have similar efficacy to lidocaine infiltration but are less painful to apply. The ideal combination and concentration of agents providing optimal levels of efficacy and safety has yet to be decided.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Pryor, GJ; Kilpatrick, WR; Opp, DR. Local Anesthesia in Minor Lacerations: Topical TAC vs Lidocaine Infiltration. Annals of Emergency Medicine 1980; 9 (11): 568-571.
2. Hegenbarth, MA; Altieri, MF; Hawk, WH et al. Comparison of Topical Tetracaine, Adrenaline and Cocaine Anesthesia With Lidocaine Infiltration for Repair of Lacerations in Children. Annals of Emergency Medicine 1990;19(1): 63-67.
3. Anderson, AB; Colecchi, C; Baronski, R et al. Local Anesthesia in Pediatric Patients: Topical TAC Versus Lidocaine. Annals of Emergency Medicine 1980;19 (5): 59-62.
4. Kendall, JM; Charters, A; McCabe, SE. Topical anaesthesia for children's lacerations: an acceptable approach? Journal of Accident and Emergency Medicine 1996;13: 119-122.
5. Smith, GA; Strausbaugh, SD; Harbeck-Weber, C et al. Comparison of Topical Anesthetics Without Cocaine to Tetracaine-Adrenaline-Cocaine and Lidocaine Infiltration During Repair of Lacerations: Paediatrics 1996; 93(3): 301-307.
6. Ernst, AA; Marvez-Valls, E; Nick, TG et al. Topical Lidocaine Adrenaline Tetracaine (LAT Gel) Versus Injectable Buffered Lidocaine for Local Anesthesia in Laceration Repair. West J Med 1997; 167 (2) :79-81.
7. Smith, GA; Strausbaugh, SD; Harbeck-Weber, C et al. Comparison of Topical Anesthetics with lidocaine infiltration during laceration repair in children. Clinical Pediatrics 1997;36 (1): 17-23.