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Abstract
A short cut review was carried out to establish whether topical anaesthetics are an acceptable alternative to lidocaine infiltration in children. A total of 54 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
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Report by Craig Ferguson, Clinical Research Fellow, and Ben Loryman, Specialist Registrar Checked by Richard Body, Clinical Research Fellow
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 yrs>; Cochrane: Laceration topical
Search outcome
Medline: 46 papers of which seven were relevant to this question (table 4); Cochrane: 8 papers, none relevant.
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.
Report by Craig Ferguson, Clinical Research Fellow, and Ben Loryman, Specialist Registrar Checked by Richard Body, Clinical Research Fellow