Topical anaesthesia for children's lacerations.

Objective-To compare the anaesthetic properties of conventional intradermal 1% plain lignocaine with a topical gel preparation of adrenaline (1:2000) and cocaine (4-7%) for use in treatment of children's lacerations. Methods-Children aged 3-16 years with lacerations (not of the digits or mucous membranes) were consecutively assigned to receive either adrenaline and cocaine (AC) or lignocaine. Pain scores, as perceived by patients, parents, and staff, were measured conventionally using Wong Baker faces and visual analogue scales on administration of the local anaesthetic and on suturing the wound in the AC group (n= 56) and the lignocaine group (n = 51). Results-Mean and median pain scores on administration of the anaesthetic in the AC group were significantly lower than in the lignocaine group as perceived by patient (P < 0.001), parent (P < 0.001), and staff (P < 0-001). There was no significant difference in mean and median pain scores between the two groups on suturing the wounds, as perceived by patient, parent and staff. There was a significantly higher number of "failed" anaesthetics (pain scores 8-10) in the lignocaine group (P < 0.01). On direct questioning the overall procedure was considered acceptable by 84505% of parents in the AC group compared with 61% of parents in the lignocaine group (P < 0-01). There were no significant complications in either group. Conclusions-Topical AC should be considered the local anaesthetic of first choice for suturing appropriate children's lacerations. (_Accid Emerg Med 1996;13: 119-122) Key terms: adrenaline/cocaine; lignocaine; topical anaesthesia; children Children are physically and psychologically different from adults, and the approach to the child in the accident and emergency (A&E) department must be appropriately modified. Whether or not this is the child's first experience in a hospital environment, it is our responsibility to ensure it is as stress-free as possible. It is no longer acceptable for children to be bundled into a blanket, held down, and sutured, leaving them with a fear of hospitals and nurses for many subsequent years. Legislation such as The Children's Act and The Audit Commission Report gives children rights to informed consent and warns the clinician against what could be perceived as physical assault by nurses who force children into treatment that they don't fully understand. Everyone who has worked in an A&E setting knows how distressing suturing children under local anaesthetic can be for the child, parents, and staff. It is not possible to explain the purpose of a local anaesthetic to a young frightened child; when conventional local anaesthesia is used, the sight of a needle, and the pain of infiltration of lignocaine, means that the child's confidence may be lost, even before the procedure to close the wound begins. A topical preparation, which is "painless" to apply, of adrenaline (1:2000) and cocaine (11 8%) is used extensively in the United States, Australia, and South Africa to locally anaesthetise children's lacerations before suturing them.1`3 There is little awareness of this preparation in the United Kingdom: a recent survey (with a 67% response rate) of 150 A&E departments seeing over 30 000 patients annually revealed that less than 5% of consultants had experience in the use of this preparation. The rationale behind using this combination of ingredients is that the cocaine provides excellent local anaesthesia, while the combination of adrenaline and cocaine causes marked vasoconstriction, thus minimising bleeding and limiting systemic absorption of anaesthetic. The objectives of our study were (1) to compare prospectively the anaesthetic properties of conventional intradermal 1% plain lignocaine with a topical gel preparation of adrenaline (1:2000) and cocaine (4.7%); and (2) to increase awareness of this preparation if its anaesthetic properties are found to be equal to lignocaine, and if its use is practical in A&E departments in this country.