International Emergency Nursing (2009) 17, 99–107

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The use of topical anaesthesia during repairof minor lacerations in Departmentsof Emergency Medicine: A literature review

Carol Little RGN Adult (Emergency Medicine Sister) a,*,Oonagh J. Kelly Bsc, Hons, Adult Nursing (Emergency Medicine StaffNurse) a,1, Mark G. Jenkins MbChB, FRCS, FCEM (Emergency MedicineConsultant) a,2, Diarmaid Murphy MPharm, PhD MPSNI (Research Fellow) b,3,Paul McCarron BSc, PhD, MRPSNI, PGCHET (Chair in Pharmaceutics) c,4

a Department of Accident and Emergency Medicine, Antrim Area Hospital, 45 Bush Road, Antrim BT41 2RL, United Kingdomb School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL,United Kingdomc Department of Pharmacy and Pharmaceutical Sciences, University of Ulster, Cromore Road, Coleraine,Co. Londonderry BT52 ISA, United Kingdom

Received 11 August 2008; received in revised form 1 October 2008; accepted 7 October 2008

17do

*

(M1

2

3

4

KEYWORDSTopical anaesthetic;Local anaesthetic;Tetracaine;Adrenaline;Cocaine;Lidocaine;Epinephrine;Minor laceration

55-599X/$ - see front matti:10.1016/j.ienj.2008.10.00

Corresponding author. TelE-mail addresses: carollit.G. Jenkins), d.j.murphy@qTel.: +44 7742257957; faxTel.: +44 2894424259; faxTel.: +44 2890972333; faxTel.: +44 8700400700; fax

er ª 2002

.: +44 77tle58@goub.ac.uk: +44 289: +44 289: +44 289: +44 289

Abstract

Background: There are currently a number of different methods available to obtain anaesthesiain minor dermatological procedures. Although intradermal infiltration of 1% lidocaine is thefavoured method for anaesthesia induction in laceration repair, it can cause significant painin 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 andcocaine) or LAT (lidocaine, adrenaline and tetracaine).Methods: A computerised search of the literature was undertaken, using Medline, Cinahl andthe Cochrane Library, to identify studies of interest to this review. Reference lists were exam-ined for further relevant papers.

8 Elsevier Ltd. All rights reserved.

16449738; fax: +44 2894424160.oglemail.com (C. Little), kelly-o3@ulster.ac.uk (O.J. Kelly), Mark.Jenkins@northerntrust.hscni.net(D. Murphy), p.mccarron@qub.ac.uk (P. McCarron).4424160.4424160.0247794.4424160.

100 C. Little et al.

Aims: This paper aims to provide an overview of the use of topical anaesthetics, in lacerationrepair, in Emergency Medicine (EM) departments.Conclusion: The literature has shown that the induction of anaesthesia in lacerations hasremained largely unchanged over the past few years, with lidocaine infiltration still the pre-ferred method. Many reasons have been put forward as to why topical anaesthetics are notcommonly used in the UK. Perhaps it would be beneficial to carry out work in relation to alter-native formulations as opposed to overcoming the difficulties associated with formulations thatare already available.

ª 2008 Elsevier Ltd. All rights reserved.

Introduction

Between 2006 and 2007, an estimated 709,329 people at-tended EM departments in Northern Ireland, with a totalof approximately 18.1 million attending EM departmentsthroughout the United Kingdom as a whole (www.statis-tics.gov.uk). As lacerations are one of the most commonlyencountered problems in EM (Hollander and Singer, 1999),it is evident that EM clinicians deal regularly with traumaticwounds. Lacerations occur predominately in young adults,of which 50% occur on the neck and head and 35% are foundon upper extremities involving finger and hands (Hollanderand Singer, 1999). The most common mechanisms of injuryinclude; application of a blunt force, sharp instruments,glass or wooden objects and bites (Hollander et al., 1995).The Manchester Triage Group state it is acceptable for pa-tients with a non-life threatening laceration to wait uptwo hours before they receive final treatment (ManchesterTriage Group, 2005), though this is dependent on painscores. However, as the NHS Plan has set new targets onwaiting times, patients should now be seen, treated, dis-charged, transferred or admitted within four hours of regis-tration to EM departments (Department of Health, 2000).This is forcing clinicians to come up with strategies that willshorten the length of time patients are required to spend inEM departments.

Methods

A computerised search of the literature was undertaken, bytwo reviewers, using Medline, Cinahl and the Cochrane Li-brary using the search terms ‘‘anaesthetics, local’’,‘‘wounds and injuries’’ and ‘‘administration, topical’’.Searches were also undertaken incorporating the text words‘‘lacerations’’, ‘‘adrenaline’’, ‘‘epinephrine’’ and ‘‘tetra-caine’’, ‘‘cocaine’’, ‘‘lidocaine’’ and ‘‘caines’’ in generalas well as ‘‘EMLA’’ and ‘‘ametop’’. Studies from all datesand of both a qualitative and quantitative nature were in-cluded. Studies carried out using both adult and paediatricparticipants were used in this literature review. Relevantpapers were retrieved and the reference lists examinedfor further articles. This paper aims to provide an overviewof the findings of the relevant papers.

Principles of laceration management

The goals of laceration management are simple and have re-mained the same over the years. These are to avoid infec-

tion and to achieve a functional and aesthetically pleasingscar (Singer et al., 1997). Such goals are achieved typicallyby reducing contamination, debriding devitalised tissue,restoring perfusion in poorly perfused wounds and estab-lishing a well-approximated skin closure (Hollander andSinger, 1999). If the wound is not appropriately managed,complications can include infection, prolonged convales-cence, unsightly and dysfunctional scars and, rarely, mor-tality (Hollander and Singer, 1999). In order to manage alaceration appropriately, the clinician must take a de-tailed history from the patient. Accounts of the mecha-nism of injury, past medical history, time elapsed frominjury, allergies and immunisation status are necessaryin order to manage and treat a laceration effectively.Pain status must be determined, as pain could be a signof an underlying fracture. In order to debride devitalisedtissue effectively, reduce contamination with good surgi-cal toilet and manipulate the wound to provide a well-approximated closure, the majority of lacerations willrequire some form of anaesthesia. It should be theprimary aim of an emergency clinician to provide effec-tive local anaesthesia with minimal pain and distortionof the tissue planes (Berman et al., 2005; Schecteret al., 2005; Gaufberg et al., 2007).

Anaesthesia of the wound

Appropriate anaesthesia of the wound is a key factor inthe treatment of minor lacerations. Currently, a numberof methods are available to obtain anaesthesia in lacera-tions prior to repair. These include intradermal infiltra-tion, field or nerve block and topical anaesthesia (Singeret al., 1997; Hollander and Singer, 1999; Schecter et al.,2005). Topical anaesthesia is of particular interest in thisreview but others will be mentioned briefly. The dose,length of anaesthetic action and clinical indications forsome commonly used anaesthetic agents are shown in Ta-ble 1. A number of local anaesthetics have been devel-oped which produce anaesthesia for different durationsof time. Although preferences for particular anaestheticagents in relation to specific procedures do exist, the mostcommonly used local anaesthetic in the UK is Lidocaine(Lener et al., 1997). As can be seen from Table 1, thereare a number of alternatives to the commonly used topicalanaesthetics and evidence from a recent review by Eidel-man et al. (2005) suggests that these are easier andcheaper to use than some of their more well knownalternatives.

Table 1 Key features of common local anaesthetics (data from Patterson, 1998).

Agents Averagedurationof action (h)

Range ofconcentrationused (%)

Maximum singledose (mg kg�1)Plain

Maximum single dose(mg kg�1) with adrenaline1:200,000 (5 lg ml�1)

Main uses

Cocaine HCI 1–2 4–25 2.5 – VasoconstrictorTopical use onlyControl drug

Procaine HCI 0.5–1 1–2 7 8.5 InfiltrationNerve block

Tetracaine HCI 3–4 0.1–1 1.5 – SpinalLidocaine HCI 1–2 0.5–5 3 7 Topical

InfiltrationNerve blockExtraduralSpinal

Prilocaine HCI 1–2 0.5–3 5.5 8.5 TopicalInfiltrationNerve blockExtraduralSpinal

Mepivcaine HCI 1.5–2 1–2 3 7 Similar to lidocaineBupivacine HCI 4–8 0.25–0.75 2 3.5 Infiltration

Nerve blockExtraduralSpinalLong duration

Etidocaine HCI 4–8 0.5–1.5 3 5.5 InfiltrationNerve blockExtraduralLong durationRelatively profound motor block

The use of topical anaesthesia during repair of minor lacerations 101

Intradermal infiltration

For young people, the necessity of using a needle, to infil-trate anaesthesia can be incomprehensible. This can becompounded if the emergency clinician assures the patientthat no pain will be felt with suturing, only to discover soonafter that it actually hurt at the moment of anaesthesiainfiltration (Adriansson et al., 2004). As a consequence,some investigators have focused on reducing the pain asso-ciated with lidocaine infiltration (Hollander and Singer,1999). For example, buffering of the solution with sodiumbicarbonate before injection has been investigated as amechanism to reduce this type of pain (Bartfield et al.,1990). Similarly, other studies have considered that warm-ing of the anaesthetic solution to body temperature reducesthe pain associated with infiltration (Bainbridge, 1991).Warming lidocaine to body temperature has found to be aseffective as the buffering approach (Brogen et al., 1995).However, these observations have been disputed by others(Krause et al., 1997). Injecting the local anaestheticthrough the wound edges, as opposed to through the intactsurrounding skin may also be useful in reducing pain associ-ated with infiltration anaesthesia (Kelly et al., 1994). Inaddition using a smaller needle gauge on children, to thatof the recommended 25 gauge, can assist in reducing infil-trative pain (Chad et al., 2007).

Besides pain, the used of infiltrative anaesthesia has an-other major disadvantage. The distortion of tissue planescaused by needle and the injection of the anaesthetic solu-tion disrupts tissue and makes suturing more difficult withan increased risk of scaring (Bonadio, 1989).

It must be noted that the use of adrenaline with lidocainecarries its own risks. Adrenaline, which is used as a vasocon-strictor, diminishes local blood flow and slows the rate ofabsorption hence prolongs the anaesthetics effect (BritishMedical Association, 2008). However adrenaline must beused in low concentration (e.g. 1 in 200,000) and must notbe given with a local anaesthetic injection in digits andappendages as it can cause ischaemic necrosis (British Med-ical Association, 2008).

Field block

Local anaesthesia may also be obtained by injecting localanaesthetic subcutaneously on the border of the area tobe anaesthetised (Hollander and Singer, 1999). This offersthe advantages of being able to anaesthetise relatively largeareas of skin using minimal doses of anaesthetic, hencereducing associated risks of toxicity (Hollander and Singer,1999). This method is particularly applicable in multiple lac-erations or when large areas of skin must be scrubbed ordebrided (Hollander and Singer, 1999).

102 C. Little et al.

Nerve block

Local anaesthetics may be injected with a high degree ofspatial accuracy in order to make contact with nerves thatsupply the affected area. Skill and a sound knowledge ofanatomy are necessary to achieve a high success rate withthe approach and to avoid complications (Chad et al.,2007). Benefits of nerve block anaesthesia include its quickonset of action, allowing an area to be anaesthetised for be-tween 60 and 120 min. Nerve block also facilitates properexamination of wound. However, the drawbacks of nerveblock include alteration of shape of the skin surface andpain when anaesthetic wears off. More seriously, failure toremove a tourniquet, if this has been used, can result inirreversible ischaemic damage before the anaesthesia wearsoff and before the patient realises (Chad et al., 2007).

Topical anaesthesia

Topical application of anaesthetics, which is non-invasive,has been investigated as an alternative to infiltration of ana-esthetics, and is often favoured by patients who are afraidof needles or unable to tolerate them (Hollander and Singer,1999; Schecter et al., 2005). It must be said that the actualanaesthetic is not changing, merely the method of delivery.The ideal topical anaesthetic should be painless to apply,provide rapid anaesthesia for a reasonable length of timeand have minimal side effects (Huang and Vidimos, 2000).Recently, the use of topical anaesthesia especially in chil-dren, has become more common (Bonadio and Wagner,1992; Schilling et al., 1995; Dart, 1998) and it has been usedfor many years in the USA and Australia (Young et al., 2005).However, UK emergency departments have been slow toembrace this practice (Bush, 2000). The majority of studies,which have investigated the use of topical anaesthesia,looked at formulations of either tetracaine (0.5%), adrena-line (0.05%) and cocaine (11.8%) (TAC) or lidocaine (4%),adrenaline (0.05%) and tetracaine (0.5%) (LAT). Table 2 pro-vides a summary of commonly used topical anaesthetics inminor laceration repair. However, other methods of obtain-ing local anaesthesia via topical agents have been studiedand will be mentioned briefly below.

Table 2 Clinical features of common topical anaesthesia (data f

Anaesthetic Method of application Onset/duration

TAC 2–5 ml applied towound with cotton woolor gauze for 10–30 min

Effective from10–30 min. Notestablished

LET 1–3 ml direct to woundfor 15–30 min

Effective in 20–30 min

EMLA Thick layer 1.2 gapplied to intact skinwith covering oftegraderm

30 min–2 h

Ametop 1.5 g applied to intactskin with covering oftegraderm

Effective in 45 mi

TAC

TAC is a mixture of tetracaine (0.5%), adrenaline (1:2000)and cocaine (11.8%), which aims to provide local anaesthe-sia, produce vasoconstriction, provide a bloodless field andslow the systemic absorption of the active anaesthetic drug.The use of TAC in laceration repair was first investigated byPryor et al. (1980). Two studies have attempted to analysewhich components are essential to produce the local anaes-thetic effect (Schaffer, 1985; White et al., 1986). Boththese studies discovered that cocaine is an important ingre-dient in TAC. Pryor et al. (1980) found that TAC providedequivalent anaesthesia, to that of lidocaine infiltration,for suturing facial lacerations and was a more acceptableapproach for laceration repair in children. In addition, theyfound that time for surgical repair was significantly reducedin those patients who received TAC for anaesthesiacompared to lidocaine infiltration (Pryor et al., 1980).Other authors have subsequently supported this approach(Hegenbarth et al., 1990; Anderson et al., 1990; Grant andHoffman, 1992; Kendall et al., 1996; Smith et al., 1997;Bonadio and Wagner, 1990; Kennedy et al., 2004).Hegenbarth et al. (1990) found there was no statisticallysignificant difference in wound complication rates inpatients who had their laceration anaesthetised with TACcompared to lidocaine infiltration.

A number of concerns regarding the use of TAC in localanaesthesia focus upon the inclusion of the cocaine compo-nent of the formulation. A 5 ml dose of TAC yields 590 mg ofcocaine and 25 mg tetracaine. Pryor et al. (1980) states thatthe toxic dose of cocaine is 1200 mg, but it has been sug-gested that doses as low as 20 mg have resulted in toxicitywhen applied to mucous membranes (Pryor et al., 1980).Improper use of TAC has been associated with adverseevents including, seizures, cardiac arrest and death. Con-cerns regarding toxicity from systemic absorption of cocainehave led to a decline in the use of TAC and the developmentof alternative topical combinations, such as LAT (Dayaet al., 1988; Grant and Hoffman, 1992; Singer et al.,1997; Dailey, 1988). Also, the administration implicationsassociated with control drugs has limited it use as a topicalanaesthetic in minor laceration repair (Bush, 2002). Bush

rom Patterson, 1998).

Effectiveness Complications

May be as effective aslidocaine infiltration onlaceration to face andscalp

Rare severe toxicity,seizures, cardiacarrest and death

Similar to TAC for faceand scalp, less effectiveon extremities

No severe adverseeffects noted

Variable depending onduration of application

Contact dermatitis

n Variable depending onduration of application

Contact dermatitis

The use of topical anaesthesia during repair of minor lacerations 103

(2000) suggested that fear of systemic side effects of co-caine, along with lack of experience, ineffectiveness andunavailability of topical formulations are some of the rea-sons why topical anaesthesia is not widely implemented inthe UK.

LAT

LAT is a combination of lidocaine, adrenaline and tetracainethat reduces the burning sensation associated with lidocaineinjections (Van-Liaw, 2001) and was first reported in the lit-erature in 1995 (Ernst et al., 1995). The investigators feltthat the exclusion of cocaine would reduce the risks of tox-icity in addition to making the product more practical, beingcheaper and free from the regulations surrounding con-trolled drugs (Ernst et al., 1995). The use of LAT has beenstudied extensively in children and has been found to beequally as effective as TAC in suturing uncomplicated lacer-ations on the face and scalp (Anderson et al., 1990; Schillinget al., 1995; Singer et al., 1997; Berman et al., 2005). How-ever, in these studies the use of LAT was confined to smallwounds (<2 cm) on the face and scalp or superficial wounds.Various combinations of lidocaine (1–4%) adrenaline(1:1000–1:2000) and tetracaine (0.5–2.0%) have been com-pared favourably with topical application of TAC, withoutthe associated risks and administrative complications of co-caine (White et al., 1986). Similarly to the use of adrenalinewith lidocaine infiltration the use of adrenaline in topicalapplication must be used with caution (British Medical Asso-ciation, 2008).

EMLA

A eutectic mixture of local anaesthetics (EMLA) was the firstsuccessful eutectic formulation for topical use. EMLA is acombination of lidocaine 2.5% and prilocaine 2.5% (Jolyet al., 1998). EMLA cream has been used as a topical anaes-thetic to reduce pain of procedures, such as phlebotomy(Nott and Peacock, 1990; Young et al., 1996; Joly et al.,1998), intramuscular injection (Taddio et al., 1994;Himelsteine et al., 1996), peripheral intravenous cannula-tion (Wig and Johl, 1990; Arts et al., 1994), skin allergy test-ing (Sicherer and Eggleston, 1997) and lumber puncture(Kapelushnik et al., 1990; Sharma et al., 1996). Zempskyand Karasic (1997) compared the efficacy of EMLA creamwith TAC before repair of extremity lacerations. Their studyfound that supplementary lidocaine infiltration was only re-quired in 15% of patients who received EMLA prior to repair,compared with 55% of patients who received TAC. However,more sutures were placed in the TAC treated wounds than inthe EMLA treated wounds and average anaesthesia applica-tion in the EMLA treated group was 55-minutes in compari-son to 29-minutes for the TAC group. Studies carried out byYamamoto and Boychuck (1998) and Loren et al. (1998)demonstrated that EMLA is not efficient after a 20-minuteapplication and studies by Nilsson et al. (1990) and Yamam-oto and Boychuck (1998) found that there was no significantdifference in pain experience in those who received EMLA asa topical anaesthetic and those who received a placebo. AsEMLA must be applied 45–60 min prior to painful proce-dures, its use in the EM setting is limited (Nilsson et al.,1990; Lurngnateetape and Tritrakarn, 1994; Vivien et al.,

1996; Zempsky and Karasic, 1997; Loren et al., 1998).Unfortunately, EMLA cream is not licensed for use on brokenskin. In addition, the slow rates of absorption and onset ofanaesthesia, coupled with the difficulties in removing theformulation from surfaces other than intact skin, make itsuse in laceration repair impractical (Nilsson et al., 1990;Lurngnateetape and Tritrakarn, 1994; Vivien et al., 1996;Zempsky and Karasic, 1997; Loren et al., 1998).

Ametop

Few studies explored the use of topical amethocaine (ame-top) prior to dermatological procedures. Browne et al.(1999) compared the superiority of ametop in relation toEMLA for its use in intravenous cannulation. This study foundthat intravenous cannulation was less painful following theapplication of ametop in comparison to EMLA. In additionto this ametop caused less vasoconstriction, which facili-tated easier intravenous cannulation. According to Choyet al. (1999) and Nott (2001) the use of ametop in childrenmay be favoured by clinicians as there is less vasoconstric-tion. Choy et al. (1999) concluded that ametop is equallyas effective as EMLA in reducing needle puncture pain, how-ever, in some circumstances ametop may be more advanta-geous for example when the patient is under 1-year-old anda quicker onset of action is required. However despite itsfavourable characteristics as a topical anaesthesia, ametopis not licensed for use on broken skin and it use therefore onlacerations prior to suture repair is limited.

Lidocaine/tetracaine (L/T) plaster (Rapydan)

The rapydan plaster, which contains 70 mg of lidocaine and70 mg tetracaine, is now licensed for use in several coun-tries of the European Union, including the UK (EUSA Pharma(Europe) Limited, 2008). Rapydan is indicated for surfaceanaesthesia of intact skin in connection with needle punc-ture in adults and children from 3 years of age, and in casesof superficial surgical procedures on normal intact skin inadults (EUSA Pharma (Europe) Limited, 2008). It has provento provide safe and effective anaesthesia for minor derma-tological procedures in patients of 65 years or over when ap-plied 30 min prior to the start of the procedure (Bermanet al., 2005; Schecter et al., 2005). However, further stud-ies are needed to explore additional indications for the useof this plaster as an alternative to topical anaesthetics thatare already available. In addition, the use of a plaster for-mulation may not be appropriate for the treatment of thewide variety of laceration topographies seen within the EMdepartment.

Use of alternative anaesthetic agents

In an effort to remove the issues surrounding the use of co-caine, several authors have considered other combinationsof topical anaesthetics. Smith et al. (1996) compared fournon-cocaine-based topical anaesthetics (bupivacaine, mep-ivicaine, etidocaine and prilocaine) with TAC. Among thesefour topical anaesthetics, bupivacaine was found to performthe best and was found to be as effective as TAC and wasparticularly effective on face and scalp lacerations. Mepiv-icaine, etidocaine and prilocaine were found to be generally

104 C. Little et al.

less effective than TAC with etidocaine being the poorestperformer. The action of topical mepivicaine–noradrena-line (mepivanor) in minor laceration repair was also subse-quently reported by Smith et al. (1997). They concludedthat this form of anaesthesia was less efficacious than TACor lidocaine infiltration. Some authors have attempted toimprove upon the effectiveness of TAC by replacing the tet-racaine component with another local anaesthetic. Kuhnet al. (1996) found in their study that a mixture of Bupiva-caine (Marcain [Astra] 0.5%), adrenaline (1:2000) and co-caine (10%) (MAC) compared favourably to TAC with nosignificant difference between the levels of anaesthesiaproduced by either solution. Although these studies mustbe recognised, further research is required in these areasin order to say with any degree of competence that theycould replace topical anaesthetics that are currently avail-able on the market.

Advantages and disadvantages of topicalanaesthetics

Among the advantages of using topical anaesthesia is theelimination of needle use and the subsequent problems ofthe pain of injection (Hollander and Singer, 1999). In addi-tion, this also eliminates the risk of inadvertent needle stickinjury and, therefore, increases worker safety within the EMdepartment (McCafferty and Woolfson, 1993; Hollander andSinger 1999). The use of a topical formulation should allowfor painless anaesthesia induction (Hollander and Singer,1999) and this should result in improved patient comfort, in-creased co-operation and satisfaction (Van-Liaw, 2001).Other advantages of topical anaesthesia could include areduction in tissue plane distortion, promoting accurate lac-eration repair, convenience of use, ease of disposal and areduction in drug loading (McCafferty and Woolfson, 1993;Hollander and Singer 1999). Finally, in an era where it is lessacceptable to restrain a child, the idea of an effective top-ical anaesthesia in conjunction with distraction therapy isvery appealing. A study by Priestley et al. (2003) found thatapplication of topical anaesthetic by the triage nurse re-duced total treatment time of such patients by 30 min.Thompson et al. (1996) stated in their study that people’sperceptions of waiting times in the emergency departmenthave been shown to be predictive of overall patientsatisfaction.

The majority of studies looking at the use of topical ana-esthetics highlight poor success on trunk and extremitywounds in comparison to scalp and facial wounds (Carpenterand Mackey, 1992; Blackburn et al., 1995; Priestley et al.,2003). Studies carried out previously highlighted that topi-cal anaesthetics had a poor success rate if their applicationwas limited to a single layer as opposed to sequential lay-ered application (Pryor et al., 1980; Bonadio and Wagner,1988; Anderson et al., 1990; Carpenter and Mackey, 1992;Grant and Hoffman, 1992; Blackburn et al., 1995; Ernstet al., 1995; Adler et al., 1998; Hollander and Singer,1999; Priestley et al., 2003). That said, the advantagesand efficacy of topical anaesthesia are well documentedin the literature. Adriansson et al. (2004) found in theirstudy that irrespective of whether a patient received intro-ductory topical anaesthesia, prior to lidocaine infiltration,they still expressed pain during laceration repair. There

are a number of other disadvantages to the use of topicalanaesthesia, especially in relation to the use of lidocaineinfiltration. These include the extended application period,the messiness of application and removal, and the inade-quate depth of penetration into intact skin that can beachieved (Bjerring and Arendt-Nielsen, 1990, DeWard-vande Spek et al., 1992). However, despite these problems,there is good evidence that topical anaesthetics are effec-tive and well-tolerated as they result in less distress for par-ents and children than the injected forms of anaesthetic(Pryor et al., 1980, Eidelman et al., 2005). The main disad-vantage of topical anaesthetics is their absorption time,which limits their use in EM settings. However novel meth-ods for enhancing topical absorption, such as iontophoresis(the use of electric current to enhance drug transport) andsonophoresis (the use of sound energy to enhance drugtransport) have been proposed and are being explored(Ernst et al., 1997; Singer et al., 1998; Katz et al., 2004).Although these methods have been shown to be effectivein inducing adequate anaesthesia, the clinical utility is off-set by the need for bulky equipment, the risk of burns andthe limited surface area which can be anaesthetised at once(Zempsky and Ashburn, 1998). There may be more effec-tive, less costly ways of reducing pain pre-procedure (Lorenet al., 1998).

Conclusion

This review has looked at the role of topical anaesthetics inlaceration management in EM departments. The literaturehas shown that within the UK, the induction of anaesthesiain lacerations has remained largely unchanged over the pastfew years. Although the literature reviewed highlights thattopical anaesthetics are safe and effective prior to lacera-tion repair, their use in UK EM departments remains limited.The uses of topical anaesthetics have been favoured by pa-tients as the visual cues associated with just seeing a needlecan potentially increase levels of stress in patients regard-less of the actual true pain it may or may not cause (Diverand Herbert, 2007), however one of the major disadvan-tages of topical anaesthetics is the delayed onset of anaes-thesia (30–90 min) compared with 45–90 s resulting fromlidocaine infiltration. Patients receiving application of topi-cal anaesthesia to the laceration at presentation to EMdepartments, by the triage nurse, could overcome this prob-lem (Priestley et al., 2003). With this in mind, it may provemore fruitful to consider research into alternative methodsof application, such as topical and regional formulations, toproduce a faster onset of anaesthesia, rather than focusingon decreasing the level of pain produced by existing meth-ods (Singer and Stark, 2000).

Conflicts of interest

There are no conflicts of interest with the authors of thisarticle.

Role of funding source

The Research and Development Office of the Northern Ire-land Health and Social Services Agency funded the authors.

The use of topical anaesthesia during repair of minor lacerations 105

Their role is to promote, co-ordinate and support researchand development within the field of health and social care.The study sponsors played no role in the writing of the man-uscript or the decision to submit the manuscript forpublication.

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