Update: Topical Anesthetics for Pain Control During Repair of Dermal Laceration
Melody Milliron, DO (EBEM Commentator), Olga Lembersky, DO (EBEM Commentator)
Department of Emergency Medicine, Saint Vincent Hospital, Erie, PA
Although further high-quality studies are needed, low-quality evidence supports cocaine-free over cocaine-containing topical agents for superficial dermal laceration anesthesia.
The search was conducted to identify studies evaluating topical anesthetics for repair of dermal lacerations. An updated search for a previous 2011 systematic review used the following databases through December 2016: Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and MEDLINE. The authors e-mailed selected journals and reviewed meta-registers of ongoing trials. Authors also contacted selected manufacturers, societies, and researchers deemed appropriate by the reviewers.
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Randomized controlled trials evaluating topical anesthetic efficacy and safety for repair of dermal laceration were selected. Studies were included only if they evaluated efficacy of topical local anesthetics for pain control during dermal laceration repair. Both amide- and ester-containing agents were included, as were multicomponent agents with vasoconstrictors. Studies were excluded if iontophoresis was used, agents were applied to mucus membranes, the laceration was closed with tape or tissue adhesive, a procedure for an infected wound was used, the wound was a complex or deep laceration, or systemic analgesics or sedatives were used before closure.
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Data Extraction and Analysis
Two authors independently analyzed the quality of trials for inclusion and reviewed study data. If any questions arose, the study authors of the original studies were contacted for further information. The Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate each study for methodological risk of bias and to assess the evidence quality. Because of the heterogeneity of the data and outcome measures, the authors could analyze the data only for pain intensity and a meta-analysis was unable to be performed.
The authors included 25 randomized controlled trials with a total of 3,278 adult and pediatric patients. They found that various topical cocaine-free agents provided adequate analgesia; however, comparison of specific agents was not possible because of high risk of bias among comparison studies. In 2 pooled studies, self-reported improvement in visual analog scale scores (0 to 100 mm), the improvement was greater for topical prilocaine-phenylephrine compared with topical tetracaine-epinephrine-cocaine, with a difference of 5.6 points.
Dermal lacerations are a common presenting complaint in US emergency departments, with more than 8 million lacerations per year.1Traditionally, local infiltration has been the technique of choice for wound anesthesia, but topical anesthetics may be preferable in pediatric and needle-averse patients.2Introduction of tetracaine-epinephrine-cocaine in 1980 appeared to be a step forward; however, concerns arose about the use of cocaine-containing agents. As cocaine became more recognized as a street drug of abuse, stricter administrative standards lessened its clinical appeal. Eventually, newer cocaine-free agents began to penetrate the market. It is not clear whether they have specific clinical advantages that would encourage their use.
Although these results suggest the benefit of cocaine-free agents, this study has several limitations. Of 5,453 search results, all but 25 were excluded. Of these, only 2 studies could be pooled that evaluated self-reported pain scales, and multiple studies included in this review had significant bias. The pain scales were not standardized across studies. Inclusion of studies with only superficial, noncomplex, 1- to 10-cm dermal lacerations may limit the applicability. Inclusion of only noninfected wounds with locations on the face, scalp, extremities, or trunk and allowing closure with only sutures or staples also limited the applicability. The authors could not separate adult or pediatric cases to determine whether there was a differential effect based on age. Despite these limitations and the overall low quality of clinical evidence, there is little evidence to support the use of cocaine-containing topical agents when cocaine-free agents are readily available.
- Mattu A, Chanmugam A, Swadron S, et al. Keep it clean: pitfalls in traumatic wound irrigation. In: Marcucci L, series ed. Avoiding Common Errors in the Emergency Department. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:889.
- Osmond MH. Wound repair and tissue adhesives. In: Moyer VA, Elliot EJ, Davis RL, et al, eds. Evidence Based Pediatrics and Child Health.London, England: BMJ Books; 2000.