Pain Management/Original ResearchApplication of topical local anesthetic at triage reduces treatment time for children with lacerations: a randomized controlled trial☆,☆☆,★
Introduction
Recent advances in anesthetic techniques have led to the wide acceptance of topical local anesthesia as a means of obtaining wound anesthesia in children.1, 2, 3 Different preparations have been used; however, there is strong evidence that these topical anesthetics are effective and well tolerated, and they result in less distress for parents and children than the injected forms of local anesthesia.4
Local anesthesia solutions currently in use in Australian emergency departments (EDs) take 20 minutes after application to become effective enough for wound repair. Current practice is that children wait to be assessed by a physician before topical local anesthesia is applied and then wait the required time for the solution to take effect before wound cleansing and repair proceeds.
An increasing number of triage protocols are being developed to facilitate the initiation of treatment when patients first arrive at the ED. Examples include triage-initiated radiographs and fast-tracking strategies.5, 6 Initial assessment is associated with shorter treatment times within the ED and may be associated with improved patient satisfaction.5, 7 The topical local anesthesia–wound repair process as it currently stands involves delays and inefficiencies that may be able to be overcome by process reengineering.
The aim of this study was to determine whether application of topical local anesthesia at triage reduced total ED treatment time for children with simple lacerations. The secondary outcome was to determine whether the requirement for sedation differed between the groups.
Section snippets
Methods
We performed a prospective, randomized, double-blind study of children aged 1 to 10 years who presented to an urban ED with simple lacerations between July 2000 and February 2001.
Children with lacerations were triaged by experienced nursing staff who used the National Triage Scale.8 Children aged 1 to 10 years who they considered might require wound repair under local anesthesia were screened for inclusion in the study. Children were excluded from the study if the wound involved the digits,
Results
Six hundred sixty-eight children presented to the ED with lacerations. One hundred eighty-three patients were randomized, and 161 cases were eligible for analysis. A flow diagram of patient selection detailing exclusions is shown in Figure 2.The most common reason for exclusion was the anatomic site of the laceration. Of the 161 cases analyzed, 84 children received ALA and 77 received placebo.
Baseline characteristics of the groups are shown in Table 1.
Discussion
This study has shown that the application of topical local anesthesia solution at triage to simple lacerations considered likely to require repair resulted in a significant reduction in total treatment time of approximately 30 minutes. This finding is important because strategies that shorten treatment time in the ED, particularly when they can be applied to common presentations, favorably affect patient flow and result in less inconvenience for patients and families. They may also be
Acknowledgements
We thank John Carlin, PhD, for additional statistical advice on study design.
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Cited by (42)
Guidelines for the use of local anesthesia in office-based dermatologic surgery
2016, Journal of the American Academy of DermatologyCitation Excerpt :In cases where topical agents alone are insufficient, the members of the work group agree that adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthesia should be considered. When more extensive surgery is required, combination of the 2 methods may also be used in select patients to avoid the need for sedation or general anesthesia.32,33 The gap in research in this important area calls for future randomized controlled trials to compare the efficacy of topical and combination of topical and infiltration anesthesia for office-based procedures in children.
Current concepts in management of pain in children in the emergency department
2016, The LancetCitation Excerpt :Nurse-driven triage protocols for pain assessment and management allow rapid initiation of pharmacological pain relief along with non-pharmacological measures such as distraction activities, positions of comfort, ice, and immobilisation.116 We encourage the adoption of standing protocols to permit triage nurses to administer analgesics rapidly to children in pain, and to apply topical anaesthesia to appropriate skin locations for those likely to need laceration repair, intravenous cannulation, or lumbar puncture.2–5,80,90,117,118 Future initiatives in emergency-department paediatric pain management will focus on developing condition-specific protocols to optimise pain recognition, assessment, and management, especially for children with cognitive impairment, recurrent pain syndromes, and chronic illness.
Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for pediatric patients? Pharmacology
2012, Annales Francaises d'Anesthesie et de ReanimationSedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for the child under spontaneous ventilation?
2012, Annales Francaises d'Anesthesie et de ReanimationInfiltration and Nerve Block Anesthesia
2012, Wounds and Lacerations: Emergency Care and Closure
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Dr. Powell is currently affiliated with the University Hospital of Wales, Cardiff, United Kingdom, and the Joseph Epstein Centre for Emergency Medicine Research, Melbourne, Victoria, Australia.
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Supported by the Morson Taylor Research Award 2000 awarded by the Emergency Medicine Foundation (Australia).
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Address for reprints: Stephen Priestley, MBBS, FACEM, Department of Emergency Medicine, Sunshine Hospital, 176 Furlong Road, St. Albans 3021, Melbourne, Victoria, Australia; 61 3 8345 1268, fax 61 3 8345 1422; E-mail [email protected] .