Clinical comparison of TAC anesthetic solutions with and without cocaine

doi:10.1016/S0196-0644(85)80925-2

Annals of Emergency Medicine

Volume 14, Issue 11, November 1985, Pages 1077-1080

https://doi.org/10.1016/S0196-0644(85)80925-2 Get rights and content

Two preparations of a topical anesthetic solution were compared with regard to their relative effectiveness, the incidence of side effects, and the occurrence of wound infection. Solution A contained tetracaine 0.5%, adrenalin 1:2,000, and cocaine 11.8%; solution B contained the same amounts of tetracaine and adrenalin but no cocaine. Children less than 10 years old who presented with facial or scalp lacerations were randomized into the A and B groups. Solution A was significantly more effective (P = .01) in producing adequate anesthesia; 8.9% of these patients required supplemental xylocaine injection, compared with 27.5% of B patients. Clinical evidence of wound infection, manifested by erythema at the time of suture removal, occurred in 7% of group A patients; none of the group B patients showed these signs. Drowsiness or excitability following the use of solutions A and B occurred in 10.7% and 7.8%, respectively. There was no convincing evidence, however, that these were causally related, nor was there any statistical correlation. Because of the effectiveness of cocaine-based topical anesthetics in the pediatric population and the relatively low incidence of side effects, including wound infection, it is recommended that topical anesthesia for dermal laceration repair be considered as an alternative to injectable xylocaine.

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Cited by (47)

The use of topical anaesthesia during repair of minor lacerations in Departments of Emergency Medicine: A literature review
2009, International Emergency Nursing
There are currently a number of different methods available to obtain anaesthesia in minor dermatological procedures. Although intradermal infiltration of 1% lidocaine is the favoured method for anaesthesia induction in laceration repair, it can cause significant pain in itself. Topical anaesthesia has been investigated as an alternative to infiltration anaesthesia, with the majority of studies looking at preparations of either TAC (tetracaine, adrenaline and cocaine) or LAT (lidocaine, adrenaline and tetracaine).
A computerised search of the literature was undertaken, using Medline, Cinahl and the Cochrane Library, to identify studies of interest to this review. Reference lists were examined for further relevant papers.
This paper aims to provide an overview of the use of topical anaesthetics, in laceration repair, in Emergency Medicine (EM) departments.
The literature has shown that the induction of anaesthesia in lacerations has remained largely unchanged over the past few years, with lidocaine infiltration still the preferred method. Many reasons have been put forward as to why topical anaesthetics are not commonly used in the UK. Perhaps it would be beneficial to carry out work in relation to alternative formulations as opposed to overcoming the difficulties associated with formulations that are already available.
Comparative efficacy and costs of various topical anesthetics for repair of dermal lacerations: A systematic review of randomized, controlled trials
2005, Journal of Clinical Anesthesia
To compare the efficacy of infiltrated local anesthesia with topical anesthesia for repair of dermal laceration, to analyze the efficacy of single or multicomponent topical anesthetics, and to identify topical formulations that are potentially less costly and equally efficacious as cocaine-containing topical anesthetics.
Systematic review of randomized controlled trials.
University-affiliated hospital.
Pediatric and adult subjects.
Twenty-two trials that randomized more than 3000 patients were identified. The majority of studies demonstrated equivalent or superior analgesic efficacy for topical formulations compared with conventional intradermal infiltration. We found that cocaine is not a mandatory component of topical anesthesia. The literature discloses no significant difference in anesthetic efficacy between topical tetracaine-epinephrine-cocaine and each of the following 6 cocaine-free formulations: lidocaine-epinephrine-tetracaine, lidocaine-epinephrine, tetracaine-phenylephrine, tetracaine-lidocaine-phenylephrine, bupivicaine-norepinephrine, or prilocaine-phenylephrine.
Topical anesthetics are an efficacious, noninvasive means of providing analgesia before suturing of dermal lacerations. The use of cocaine-containing topical anesthetics can no longer be justified in light of its high cost and potential adverse effects. We have summarized the evidence, mostly favorable, supporting the use of various non–cocaine-containing topical anesthetics.
Topical anesthetics in dermatology
2000, Journal of the American Academy of Dermatology
Citation Excerpt :
Bonadio and Wagner94 showed that a “half strength” TAC (0.25% tetracaine and 5.9% cocaine)105 or a combination of 11.8% cocaine and adrenaline 1:2000 provided efficacy similar to that of TAC on pediatric facial and scalp lacerations.94 Removing cocaine (a controlled substance) from TAC, Schaffer89 noted decreased analgesic efficacy. Bonadio and Wagner106 demonstrated that a gel-based formulation consisting of 11.8% cocaine and adrenaline 1:2000 with methylcellulose as an emulsifying agent decreased the risk from runoff of liquid medication onto mucosal or ocular surfaces.
Topical anesthetics are valuable tools for the dermatologists. The purpose of this study is to educate dermatologists about the pharmacology and clinical applications of topical anesthetics. A review of the current topical anesthetics was conducted. Several topical anesthetics are available to provide safe and effective cutaneous analgesia. Patient care can be improved by reducing the discomfort of local procedures and by minimizing the side effects of the anesthetics. (J Am Acad Dermatol 2000;43:286-98.)
Cocaine absorption after application of a viscous cocaine-containing TAC solution
1999, Annals of Emergency Medicine
Study objectives: We sought to measure plasma cocaine and benzoylecgonine levels in children after application of a solution of a topical anesthetic containing tetracaine 0.5%, epinephrine 1---2,000, and viscous cocaine 5.9% (TAC) to lacerations requiring suture repair. Previous reports demonstrating cocaine absorption used aqueous cocaine. The purpose of this study is to determine whether systemic absorption occurs with viscous cocaine.
Methods: We used a convenience sample of children in a pediatric emergency department during the summer months of 1994 and 1995. Participants were pediatric patients less than 15 years of age with simple lacerations requiring suturing.
Results: Twenty-five patients were enrolled in the study. The mean age of the patients was 8.5 years (range, 3 to 13 years). Lacerations tended to be small, with a mean length of 2.2 cm (range, 1 to 8 cm). Plasma cocaine and benzoylecgonine levels were measured by means of high-performance liquid chromatography. The mean time for obtaining the plasma sample for cocaine analysis was 67.2±23.9 minutes (range, 28 to 130 minutes) after application of the viscous cocaine-containing TAC solution. Qualitative assay results, which were accurate to 50 ng/mL, were negative in all 25 patients for both plasma cocaine and benzoylecgonine. No child demonstrated any signs or symptoms suggestive of cocaine toxicity.
Conclusion: In our study, application of viscous cocaine-containing TAC solutions to small lacerations did not produce clinically important cocaine absorption.
Topical anesthesia for pediatric lacerations: A randomized trial of lidocaine-epinephrine-tetracaine solution versus gel
1998, Annals of Emergency Medicine
Study objective: To compare the adequacy and efficacy of anesthesia experienced with lidocaine-epinephrine-tetracaine (LET) solution versus LET gel during suturing of uncomplicated lacerations on the face or scalp in children. Methods: Two hundred children with lacerations of the face and scalp requiring suturing were enrolled in this blinded, randomized controlled trial, in the emergency department of a university-affiliated children’s hospital. After the application of anesthetic solution or gel, adequacy of anesthesia was determined before suturing. Efficacy of anesthesia during laceration repair was determined by the length of time after removal of the topical anesthetic to the first sign of discomfort that required additional anesthesia or until suture completion. Results: Adequacy of initial anesthesia was equivalent between LET solution and LET gel. There was a significant difference in efficacy of anesthesia between the LET formulations. There were more patients with complete anesthesia (85% versus 76%), fewer persons with partial anesthesia (5% versus 21%), and more persons with incomplete anesthesia (9% versus 3%) in the gel group. Conclusion: LET gel is at least as effective as LET solution and possesses theoretical advantages for topical anesthesia during suturing of uncomplicated lacerations on the face and scalp in children.[Resch K, Schilling C, Borchert BD, Klatzko M, Uden D: Topical anesthesia for pediatric lacerations: A randomized trial of lidocaine-epinephrine-tetracaine solution versus gel. Ann Emerg Med December 1998;32:693-697.]
LAT (lidocaine-adrenaline-tetracaine) versus TAC (tetracaine-adrenaline-cocaine) for topical anesthesia in face and scalp lacerations
1995, American Journal of Emergency Medicine
The study objective was to compare the topical anesthetic LAT (4% lidocaine, 1:2,000 adrenaline, 1% tetracaine) to TAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine) for efficacy, adverse effects, and costs. The study design was a randomized, prospective, double blind clinical trial set in an inner-city emergency department with an emergency medicine residency program. Adults with linear lacerations of the face or scalp were eligible for inclusion in the study. Patients had lacerations anesthetized with topical TAC or LAT according to a random numbers table. A total of 95 patients were included in the study with 47 receiving TAC and 48 receiving LAT. Patients stated the number of sutures causing pain and patients and physicians rated the overall pain of suturing using a standard visual analog scale (VAS). The power of the study to determine a ranked sum difference of 15 was 0.8. Visual analog scale results and number and percentage of sutures causing pain were compared using Wilcoxon's Rank Sum Test. According to patients, the percentage of sutures causing pain was significantly fewer for LAT than TAC (P = .036, Interquartile Range 0.13 to 0.0 for LAT, 0.25 to 0 for TAC). Physicians found LAT statistically more effective than TAC (P = .0093, Interquartile Range 1 to 0 for LAT, 2 to 0 for TAC) but patients did not report a difference (P = .266, Interquartile Range 1 to 0 for both LAT and TAC). Our cost per application was $3.00 for LAT compared to $35.00 for TAC. Follow-up was accomplished in 91 of 95 patients (95%) with no reported complications for either medication. In conclusion, LAT worked at least as effectively as TAC for topical anesthesia in facial and scalp lacerations. Considering the advantages of a noncontrolled substance and less expense, LAT seems to be better suited than TAC for topical anesthesia in laceration repair.

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Original contributionClinical comparison of TAC anesthetic solutions with and without cocaine

Ann Emerg Med

Ann Emerg Med

Original contribution
Clinical comparison of TAC anesthetic solutions with and without cocaine