Pain Management/Original Research
Application of topical local anesthetic at triage reduces treatment time for children with lacerations: a randomized controlled trial,☆☆,

Presented at the Australasian College for Emergency Medicine annual scientific meeting, Hobart, Tasmania, Australia, October 2001.
https://doi.org/10.1067/mem.2003.207Get rights and content

Abstract

Study objective: We determine whether application of topical local anesthetic at triage reduces total treatment time for children with simple lacerations. Methods: This prospective, randomized, double-blind, controlled trial was conducted in an urban pediatric emergency department (ED). Participants were children who were aged 1 to 10 years and had simple lacerations. Exclusions were wounds to digits, ears, penis, nose, or mucous membranes; wounds close to the eye; deep wounds involving bone, cartilage, tendon, or vessels; wounds older than 6 hours; allergy or previous reaction to local anesthetics; trivial wounds unlikely to require any intervention; previous anesthesia to area before presentation; and failure to obtain consent. Participants were randomized to application of adrenaline 1:1,000, lignocaine (lidocaine) 4%, and amethocaine 0.5% (ALA) or placebo (adrenaline 1:1,000 solution) at triage. The primary outcome measure was total treatment time (triage time to discharge time). Secondary outcomes were the proportion of children from each group who required sedation and subgroup analysis by mode of wound closure. Analysis was by Mann-Whitney U test comparing times and χ2 test comparing sedation rate. Results: One hundred sixty-one patients were eligible for analysis (84 ALA, 77 control). Sixty-five patients were sutured, 84 were treated with glue, 6 were treated with Steristrips, and 6 were not provided with formal closure. The median treatment time for the ALA group was 77 minutes compared with 108 minutes for the control group (effect size 31 minutes; 95% confidence interval 15 to 47 minutes; P =.0019). There was no difference in requirement for sedation between the groups. Conclusion: The application of ALA at triage significantly reduces total treatment time for children with simple lacerations.

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.

. Participant selection.

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.

. Characteristics of

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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    Needle-free jet injection of subcutaneous local anesthetic is another option with rapid onset that may be less painful than needle delivery.11–13 Several passive diffusion topical gels and creams, such as 2.5% lidocaine/2.5% prilocaine cream,14,15 a lidocaine/tetracaine patch, and liposomal lidocaine cream, are efficacious but are limited by a relatively long onset (20–60 minutes), cutaneous vasoconstriction, or difficult application. Iontophoresis-driven, heat-assisted, laser-assisted, or ultrasound-assisted transit of lidocaine through the stratum corneum has a faster onset than passive diffusion strategies, but these techniques are associated with a higher risk of skin irritation or discoloration and, in some cases, with the potential for skin burns; they also require specialized equipment and training.16

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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.

☆☆

Supported by the Morson Taylor Research Award 2000 awarded by the Emergency Medicine Foundation (Australia).

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] .

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