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Three Part Question

In [patients requiring closure of lacerations] are [Tetracaine Adrenaline Cocaine preparations better than Lignocaine Adrenaline Tetracaine preparations] in [reducing the pain associated with suturing]?

Clinical Scenario

An 8 year old child has a 5cm laceration that requires closure with sutures. You wonder if TAC or LAT would be more effective in reducing the pain of suturing.

Search Strategy

Medline 1966 to 2004.
[lignocaine or lidocaine or exp lidocaine] AND [tetracaine or exp tetracaine] AND [adrenaline or epinephrine] AND [cocaine or exp cocaine]. Search strategy repeated in Cochrane and Embase databases.

Search Outcome

Search outcome 33 papers of which 30 were irrelevant. No additional relevant papers identified in Embase or Cochrane.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ernst AA, Marvez-Valls E, Nick TG and Weiss SJ. 1995 USA	95 Adults with lacerations on the face of scalp.	RCT.	Inadequate anaesthesia for suturing.(TAC vs LAT)	6% vs 2%(p value not given).	Figures in demographic data table don't add up. Study doesn't assess efficacy on other areas of the body. Study compares efficacy on adults not children.
			Visual analogue scores of pain during suturing.	No difference in patients' pain scores during suturing.
			Percentage of sutures causing pain.	Median of 0% vs 0%, maximum of 0.8% vs 0.4% (p=0.036)
Schilling CG, Bank DE, Borchet BA, Klatzko MD, Uden DL 1995 USA	171 Children aged 1 to 17 with lacerations on the face or scalp.	RCT.	Percentage of wounds anaesthetised to a 27 gauge needle prior to suturing.(TAC vs LAT)	80% vs 74% (p=0.46)	Study doesn't assess efficacy on other areas of the body. No sample size calculation.
Ernst AA, Marvez-Valls E, Nick TG Chin E, Wood E and Gonzaba T. 1995 USA	95 Children aged 5 to 17 with lacerations on the face of scalp.	RCT.	Inadequate anaesthesia for suturing. (TAC vs LAT)	6% vs 4% (p=0.48)	Subjective definition of inadequate anaesthesia. Study doesn't assess efficacy on other areas of the body. It is unclear how the power analysis relates to clinical benefit.
			Multidimensional pain scores of pain during suturing.	No difference in pain scores during suturing.
			Percentage of sutures causing pain.	13% vs 18% (p=0.51)

Comment(s)

There is no convincing evidence of a clinically meaningful difference between TAC and LAT, although it is unclear whether any of these studies is adequately powered to answer this question conclusively. It is unfortunate that none of the three papers address the relative efficacy of TAC and LAT on parts of the body other than the face and scalp.

Editor Comment

ST

Clinical Bottom Line

There does not appear to be any difference in the efficacy of TAC or LAT mixtures in reducing the pain of suturing lacerations on the face or scalp. Your choice will be determined by local availability.

References

1. Ernst AA, Marvez-Valls E, Nick TG and Weiss SJ. LAT versus TAC for topical anaesthesia in face and scalp lacerations American Journal of Emergency Medicine 1995; 13: 151-154.
2. Schilling CG, Bank DE, Borchet BA, Klatzko MD, Uden DL Epinephrine and Cocaine (TAC) versus Lidocaine, Epinephrine and Tetracaine (LET) for anaesthesia of lacerations in children. Annals of Emergency Medicine 1995; 25(2): 203-208.
3. Ernst AA, Marvez-Valls E, Nick TG Chin E, Wood E and Gonzaba T. LAT gel versus TAC gel for topical anaesthesia in linear face and scalp lacerations in children aged 5 to 17 years. Paediatrics. 1995; 95: 255-258.