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Is Cocaine Needed in Topical Anaesthesia? S Bush

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Is Cocaine Needed in Topical Anaesthesia? S Bush 418 Emerg Med J: first published as 10.1136/emj.19.5.418 on 1 September 2002. Downloaded from CLINICAL TOPIC REVIEW Is cocaine needed in topical anaesthesia? S Bush ............................................................................................................................. Emerg Med J 2002;19:418–422 Are non-cocaine containing topical anaesthetics as METHODS effective as cocaine containing topical anaesthetics in The Medline database (1966–2000) was searched using the Ovid search engine. MeSH headings of the management of lacerations? This review examines “Anesthesia, local”, “Anesthetics, local” and the current medical literature for effective agents that do “Administration, topical” were used. Searches not contain cocaine. were also made using “topical anesthesia” and “topical anaesthesia” as keywords. The results .......................................................................... generated were combined with those from the MeSH headings “Wounds, nonpenetrating” and “Pain hurts”. “Wounds,penetrating” and the keywords “lacera- tion” and “incision”. The combined articles were The standard local anaesthesia technique used limited to “English language” and “randomised in UK practice before suturing is infiltration with controlled trial”. 1% plain lignocaine (lidocaine).1 This method is Another electronic search was made of Medline painful but does give good anaesthesia.2–4 using the Internet Grateful Med search engine. Topical anaesthesia (TA) has been used in the The query terms were “topical anesthesia or topi- United States for two decades.5 The rationale cal anaesthesia” with limitation to “Human” and behind its use was to avoid the needle prick and “Randomised Controlled Trial”. The databases pain of infiltration while producing effective EMBASE, COCHRANE LIBRARY and BEST EVI- anaesthesia. There is also no tissue distortion DENCE CD were also searched in a similar man- with topical anaesthesia unlike subcutaneous ner. The internet was searched for “topical infiltration. anesthesia” and “topical anaesthesia” using the The original mixture used for topical anaesthe- Dogpile site. sia was TAC—0.5% tetracaine, 0.05% adrenaline All of the references of the chosen papers were (epinephrine), and 11.8% cocaine5 although a examined to identify other relevant papers. The number of departments use different concentra- journals Annals of Emergency Medicine and Journal tions of the three drugs.6–9 of Accident and Emergency Medicine were hand Application of TAC is less painful than infiltra- searched from 1994–2000. tion of lidocaine.5 9–11 In wounds of the face and http://emj.bmj.com/ scalp the anaesthetic effectiveness of TAC is equivalent to 1% lignocaine.5 12–15 Some studies RESULTS have demonstrated equivalence with extremity Tables 1, 2, 3, and 4 show the results of the litera- 5710 wounds but other publications report that ture search. TAC is inferior to 1% lidocaine in this Sixteen relevent papers have been identified by 13 14 situation. Wound complication rates are simi- the search strategy. Five studies216232429compared lar for both drugs.6 7–11 15 16 Most comparisons with an agent comprising lignocaine, tetracaine, and on September 30, 2021 by guest. Protected copyright. lidocaine have been made only in children but 5 vasoconstrictor with either TAC or 1% lidocaine some have included adults. infiltration. In all but one study29 the agent There are a number of drawbacks associated performed at least as well as the control. Applica- with the use of TAC. TAC is expensive691516and as tion of the topical agent is less painful than a controlled drug, it is inconvenient to store and 2 29 34 infiltration. Tetralidophen performed less use. The most significant problems with TAC, well. Lignocaine with epinephrine works well.15 however, are the rare but catastrophic complica- Tetracaine alone is a poor topical agent28 as it is tions of its use. There are several reports of with adrenaline27 or 2.5% phenylephrine 29 34 but seizures associated with its use in children.17–20 with 5% phenylephrine34 it is similar to TAC. There is also a case report of the death of a child Prilophen has been used in three studies by the that has been attributed to the rapid absorption of cocaine via mucous membranes.21 Cocaine has same investigators. In two studies, it was less effective than lidocaine infiltration and TAC32 34 been detected in the plasma of children treated 33 with TAC.22 The majority of departments that use but in one study the results were similar. TAC is superior to prilonor.7 EMLA cream works better TAC avoid its use on mucous membranes but not 31 all.19 than TAC on extremity wounds in children but is Reducing the concentration of cocaine in TAC not licensed for use on broken skin in the UK. ....................... 78 7 33 has been proposed to improve its safety profile6–9 Mepivanor, etidonor, and bupivaphen alle- Correspondence to: but the safety issues remain, as do the cost and viate less pain than TAC or lidocaine infiltration. S Bush, Accident and inconvenience factors. It is logical, therefore, to Emergency Department, St seek an agent that does not contain cocaine but is James’s University Hospital, ................................................. Leeds LS9 7TF, UK; as effective in topical anaesthesia as TAC. The [email protected] purpose of this review is to examine the literature Abbreviations: TA, topical anaesthesia; TAC, tetracaine, ....................... for evidence of such an agent. adrenaline, cocaine www.emjonline.com Non-cocaine containing topical anaesthetics 419 Emerg Med J: first published as 10.1136/emj.19.5.418 on 1 September 2002. Downloaded from Table 1 Agents using strong lignocaine (lidocaine) Group Agents Population Score Results Ernst et al23 3mlofTACv3mlofLAT(4% Adults. VAS of suturing by patient + LAT caused fewer painful lidocaine, 1/2000 adrenaline, Wound <7 cm on face or physician. sutures p=0.036 1% tetracaine scalp. Number of painful sutures by Median VAS for TAC + LAT by Applied for up to 30 minutes. 47 TAC physician. both groups = 0 48 LAT Ernst et al2 1% buffered lidocaine with 5 years and older. VAS of application and suturing VAS for application strongly epinephrine v 3 ml LAT gel (4% Wound 1.5–10 cm and linear. by patient + physician favours LAT p=0.001 lidocaine, 1/2000 adrenaline, 33 Lido Number of painful sutures by 13% sutures caused pain with 0.5% tetracaine). 33 LAT gel physician. LAT, 6% with lidocaine P=0.28 Gel applied for up to 20 No difference in VAS for minutes. suturing Schilling et al16 3mlofTACv3mlofLET(4% Children. Adequacy of anaesthesia. Equivalent adequacy of lidocaine, 1/1000 Wound covered by 2×2cm Duration of anaesthesia. anaesthesia (TAC 79.5%, LET epinephrine, 0.5% tetracaine). gauze on face or scalp. 74.4% p=0.45). Applied for 15 minutes. 73 TAC Equivalent numbers with 78 LET complete duration of anaesthesia (TAC 75.9%, LET 82.4% p=0.18). Ernst et al24 3 ml TAC gel v 3 ml LAT gel - Children 5–17 years VAS of suturing by patient or No difference in number of (4% lidocaine, 1/2000 Wound <7 cm on face or parent and physician. painful sutures (TAC 13%, LAT adrenaline, 0.5% tetracaine). scalp. Number of painful sutures by 18% p=0.51). Applied for up to 30 minutes 47 TAC parents or patients. No difference between LAT and 48 LAT TAC ranked sum ratings for physicians (p=0.80) or patients (p=0.71). Resch et al25 3 ml LET (4% lidocaine, Children. Adequacy to needle probe No difference in adequacy 1/1000 epinephrine, 0.5% Wound covered by 5×5cm Efficacy of anaesthesia between solution and gel tetracaine) solution v 3mlLET gauze on face or scalp. (95% CI −8% to 13%) gel. 91 Gel Similar numbers with complete Applied for 20 minutes. 103 Solution effectiveness (95% CI −3% to 22%) Blackburn et al15 10 ml TAC v 10 ml TLE (5% 2 years and older. Facial effective scale (9 points) Similar results lidocaine, 1/2000 Wound of face or scalp. by physician or older child. TAC mean score 2.66, TLE epinephrine) 18 TAC 3.29 (p=0.33). Applied for 20 minutes. 17 TLE Both scores within “complete anaesthesia” range Adler et al26 demonstrated that LET (4% lidocaine, 1/1000 epinephrine, 0.5% tetracaine) worked significantly better than sterile water. Table 2 Non-cocaine TAC derivatives Group Agents Population Score Results http://emj.bmj.com/ Schaffer et al27 2mlTACv2mlTA(No Children 10 years and younger. Physician effectiveness. More in the TA group required cocaine). Wound above the neck. extra infiltration 27.5% TA v Applied for 10 minutes 56 TAC 8.9% of TAC (p=0.01). 51 TA 82% TAC had completely effective anesthesia, 65% TA (p=0.13) White et al28 5 ml 0.5% tetracaine v 5ml Over 18 years VAS of procedure. 36% TAC required extra TAC Wound <5 cm Not scored if infiltration used. infiltration, 59% tetracaine. Applied for up to 10 minutes. 36 TAC TAC group had less pain, Mean 32 Tetracaine VAS on September 30, 2021 by guest. Protected copyright. TAC 1, tetracaine 3.7, (p<0.05). Bupivanor7 is as effective as TAC and lidocaine infiltration. The headings in an attempt to improve sensitivity. Alternative wound infection rate was low in all studies. spellings of certain keywords further increase the sensitivity. By using the references of the articles chosen to generate fur- DISCUSSION ther papers and hand searching the two journals thought Principal results most likely to be relevant, more articles were found. Fourteen different non-cocaine containing topical anaesthet- Despite this strategy, it is unlikely that all the relevant ics have been studied. Of these, agents with 4% or 5% papers will have been chosen. There may be other journals lidocaine,21516 bupivanor,7 and tetraphen34 have similar effec- that may produce a relevant article but that may be tiveness to TAC or 1% lidocaine infiltration.
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