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Topical anaesthetics for repair of dermal laceration

  1. Anthony Eidelman1,*,
  2. Jocelyn M Weiss2,
  3. Cristy L Baldwin3,
  4. Ikay K Enu4,
  5. Ewan D McNicol5,
  6. Daniel B Carr6

Editorial Group: Cochrane Anaesthesia Group

Published Online: 15 JUN 2011

Assessed as up-to-date: 22 MAR 2011

DOI: 10.1002/14651858.CD005364.pub2


How to Cite

Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB. Topical anaesthetics for repair of dermal laceration. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005364. DOI: 10.1002/14651858.CD005364.pub2.

Author Information

  1. 1

    Barnes Jewish Hospital, Washington University School of Medicine, Department of Anesthesiology, Division of Pain Medicine, St Louis, MO, USA

  2. 2

    American College of Cardiology, Science and Quality Division, Washington, DC, USA

  3. 3

    University of Kansas School of Medicine-Wichita, Department of Pediatrics, Wichita, Kansas, USA

  4. 4

    University of Maryland, Department Anesthesiology, Baltimore, USA

  5. 5

    Tufts Medical Center, Departments of Pharmacy and Anesthesiology, Boston, Massachusetts, USA

  6. 6

    Tufts Medical Center, Department of Anesthesia, Boston, USA

*Anthony Eidelman, Olathe Medical Center, 20375 West 151st Street, Suite 306, Olathe, KS, 66061, USA. Anthony_eidelman@yahoo.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 15 JUN 2011

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. topical local anaesthetics compared to infiltrated local anaesthetics or other topical agents for repair of dermal lacerations

topical local anaesthetics compared to infiltrated local anaesthetics or other topical agents for repair of dermal lacerations

Patient or population: patients with repair of dermal lacerations

Settings:

Intervention: topical local anaesthetics

Comparison: infiltrated local anaesthetics or other topical agents

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

infiltrated local anaesthetics or other topical agentstopical local anaesthetics

Cocaine-containing topical anaesthetics versus infiltrated local anaestheticsSee commentSee commentNot estimable1006
(6 studies)
⊕⊕⊝⊝
low1
Unable to mathematically combine results because of heterogeneity of outcome measures

Comparisons between different cocaine-containing topical anaestheticsSee commentSee commentNot estimable530
(4 studies)
⊕⊕⊝⊝
low2
Unable to mathematically combine results because each topical anaesthetic comparison limited to a single study

Cocaine-free topical anaesthetics compared to infiltrated local anaestheticsSee commentSee commentNot estimable393
(4 studies)
⊕⊕⊝⊝
low3
Unable to mathematically combine results because of heterogeneity of outcome measures

Cocaine-free topical anaesthetics compared to cocaine-containing topical anaestheticsSee commentSee commentNot estimable1231
(11 studies)
⊕⊕⊝⊝
low4
Two of the eleven trials studied a common topical anaesthetic and could be mathematically combined

Comparisons between different cocaine-free topical anaestheticsSee commentSee commentNot estimable656
(5 studies)
⊕⊕⊕⊝
moderate5
The trials could not be mathematically combined because each study compared a different cocaine-free topical anaesthetic

Anaesthetic related adverse effectsStudy populationRR 0
(0 to 0)
1686
(11 studies)

1 per 10000 per 1000
(0 to 0)

Medium risk population


*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Each of the trials had high risk of bias in multiple domains or unclear risk of bias in three domains
2 Two of the four trials had at least one domain that was high risk of bias
3 Two of the trials had unclear risk of bias in multiple domains and the other two studies had high risk of bias in two domains
4 Six of the studies had high risk of bias for at least one domain and the other five studies had unclear risk of bias for one or more domains
5 Each of the five trials had unclear risk of bias in one or more domains. However, none of the trials contained any domains that were clearly high risk

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Pain caused by repair of torn skin may be an unpleasant experience for patients. Analgesia or pain control is conventionally achieved through local anaesthetic infiltration. Local anaesthetics are a class of drugs that interrupt the transmission of electrical impulses along sensory nerves by inactivating sodium channels (Stoelting 1999). However, the infiltration of local anaesthetics, which involves injecting the medication into the skin, may itself cause significant pain (Kundu 2002). Many patients, especially children, fear or dislike needles. Topical anaesthetics are not injected. Rather, the agent is directly applied to a local area or the skin. Therefore, topical anaesthesia may be preferable to infiltration anaesthesia for pain control during skin laceration repair. There are several different forms of topical anaesthetics, including solutions, gels, creams, ointments and skin patches. Adverse reactions to topical local anaesthetics include local responses (rash, stinging) or systemic allergic reactions (diffuse swelling, difficulty breathing, anaphylaxis) (Drug Facts 2003). An overdose with topical local anaesthetics may adversely affect the cardiovascular or central nervous systems (Drug Facts 2003). Untoward effects from high systemic levels of local anaesthetics include hypotension, cardiac arrhythmias (bradycardia, ventricular fibrillation, asystole), light-headedness, double vision, a metallic taste, drowsiness and seizures (Stoelting 1999).

In 1980, Pryor et al published the initial report of successful topical anaesthesia for repair of torn skin (Pryor 1980). The initial formulation, tetracaine-adrenaline-cocaine (TAC), gained widespread acceptance in North America and has largely supplanted infiltration anaesthesia for this purpose (the term 'epinephrine' rather than 'adrenaline' is used in the USA) (Grant 1992). However, the necessity to employ cocaine in topical anaesthetic formulations has been questioned due to concern over possible adverse effects (Bush 2002; Grant 1992). Although the application of TAC to skin lacerations results in undetectable or low systemic cocaine levels (Terndrup 1992, Vinci 1999), inadvertent mucosal application or overdose may cause significant cocaine absorption, resulting in serious consequences such as seizures (Dailey 1988; Daya 1988;Tipton 1988; Wehner 1984). Moreover, there are administrative and financial burdens of dispensing a controlled substance that is widely abused in the community. Accordingly, in the past decade novel preparations of cocaine-free topical anaesthetics have been developed. Analysis of the efficacy and safety of established and recently developed topical anaesthetics is needed.

Anaesthetic efficacy (capacity for producing desired anaesthetic effect) during procedures such as wound repair is reflected by the patient's self report of pain intensity during the intervention. Acceptable tools to quantify pain intensity include the visual analogue scale (VAS), numeric rating scale, verbal rating scale, faces scale or other validated descriptors of pain intensity. Non-concordance has been demonstrated between patients' and practitioners' assessments of procedure-related pain (Choiniere 1990; Singer 1999; Stephenson 1994).

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

  1. To compare the efficacy of infiltrated local anaesthetic agents with that of topically applied local anaesthetic agents for repair of dermal (skin) lacerations. We determined anaesthetic efficacy by the patient's self report of pain intensity during repair of the wound.
  2. To compare the efficacy of various single or multi-component topical anaesthetic agents for repair of dermal lacerations.
  3. To identify cocaine-free, topically applied local anaesthetics that are potentially as efficacious as cocaine-containing topical anaesthetics.
  4. To compare the safety of the various topically applied local anaesthetic agents and preparations.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included only randomized, controlled trials (RCTs) or quasi-randomized trials. We included relevant trials that were published in abstract format or presented at national or international society meetings. We attempted to locate unpublished studies by contacting relevant manufacturers and investigators. We did not consider data from review articles, case reports or letters to the editor.

 

Types of participants

We included adult and paediatric patients of either sex. We did not set a minimum age threshold, so that we could identify as many relevant studies as possible.

 

Types of interventions

We only included trials that evaluated the efficacy of topical local anaesthetics for repair of dermal (skin) lacerations. We included comparisons between:

1. infiltrated local anaesthetic agents with topically applied local anaesthetic agents;

2. different topical local anaesthetic formulations.

We defined topical anaesthetics as any agents that are directly applied to the skin in order to produce numbness. We included both amide and ester local anaesthetics. We accepted topical preparations that contain more than one local anaesthetic. We also included multi-component topical anaesthetics that contain vasoconstrictors (that is, cocaine, adrenaline). Acceptable forms of topical local anaesthetics included solution, gel, cream, ointment, lotion, jelly, balm, or aerosol spray. We excluded studies that administered local anaesthetics using iontophoresis (a mild electrical current).
We excluded papers that applied topical anaesthetics to mucous membranes (moist linings of the mouth, nose, and eyes). In order that the procedures that were evaluated involved an approximately equivalent intensity and quality of pain, we limited the technique of skin closure to instrumentation including suture placement or stapling. Less invasive approaches to repair lacerations, such as application of tape or tissue adhesives, were excluded. We included only superficial injuries that involved the epidermis or dermal layers. We did not consider deeper wounds involving the fascia or non-skin structures. We set no limitations on the dimensions of the laceration, but we excluded procedures on infected wounds. We also excluded studies that administered systemic analgesics or sedatives that may alter the accuracy of the patients' perceived pain intensity or report.

 

Types of outcome measures

 
Primary outcome

Patient report of pain intensity during wound repair

 
Secondary outcomes

1. Incidence of topical anaesthetic failure, requirement for supplemental anaesthesia, patient's acceptance of anaesthesia, patient behavioural responses, and surrogate pain scores provided by the physician, parent or other observers

2. Topical anaesthesia-related acute toxicity and adverse effects (allergic reaction, neurological and cardiovascular toxicity)

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Central Registrar of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10); MEDLINE (1966 through November 2010); EMBASE (1980 through November 2010) and CINAHL (1982 through November 2010).

We sought unpublished studies by directly contacting the primary investigator for the included trials. We searched for additional papers by reviewing the references of each retrieved study.

We searched MEDLINE, CENTRAL and CINAHL using the search strategy described in Appendix 1, Appendix 2 and Appendix 3. We combined the MEDLINE search with the first two levels of the optimal trial search strategy (Higgins 2011). We searched EMBASE using the search strategy found in Appendix 4.

We searched metaregisters of ongoing trials (http://www.controlled-trials.com/ and http://clinicaltrials-dev.ifpma.org/).

All trials were limited to human studies. We did not implement any language restrictions in the literature search.

 

Searching other resources

We manually searched the following journals (1980 through 2009):

  1. Academic Emergency Medicine,
  2. Annals of Emergency Medicine,
  3. Emergency Medicine Clinics of North America,
  4. Journal of Emergency Medicine,
  5. Emergency Medicine Australasia (formerly known as Emergency Medicine).

We reviewed abstracts presented at the following national or international society meetings:

  1. American Academy of Pain Medicine (AAPM),
  2. American Pain Society (APS),
  3. American College of Emergency Physicians (ACEP),
  4. American Society of Anesthesiologists (ASA),
  5. American Society of Regional Anesthesia and Pain Medicine (ASRA),
  6. The European Society of Regional Anaesthesia and Pain Therapy (ESRA),
  7. Society for Academic Emergency Medicine (SAEM).

We contacted the following manufacturers of topical anaesthetics for ongoing or unpublished trials:

  1. Astra Zeneca,
  2. Endo Pharmaceuticals,
  3. Ferndale Laboratories,
  4. New England Compounding Center,
  5. Smith and Nephew,
  6. Topicaine.NET.

 

Data collection and analysis

 

Assessment of studies for inclusion in the review

Two authors (AE and either CB or IE) independently reviewed the study titles and abstracts identified by the search strategy. We obtained the full publications if at least one author decided that the study potentially met the inclusion criteria. Two authors (AE and CB or IE) independently examined the complete articles and selected trials that met the inclusion criteria. In the event of disagreement, another author (DC) was consulted.

 

Data extraction

We compared the retrieved information to verify accuracy and resolved disagreements by consensus. In studies that presented the results in bar graph format (Anderson 1990; Ernst 1990; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a), two authors (AE, IE) independently extracted numerical data by measuring graphs with a ruler. The average of the two measurements was then calculated. In one RCT we calculated the standard deviation (SD) for each experimental group's mean pain score by multiplying the standard error of the mean (SEM) by the square root of the sample size (Smith 1997b). In three studies we calculated the mean pain scores and SDs from individual patient data (Anderson 1990; Ernst 1990; Gaufberg 2007). White and associates reported the results in separate groups, according to the characteristics of the laceration (length and location) (White 1986). We pooled pain scores for each anaesthetic group and reported the results collectively. Furthermore, in order to facilitate statistical comparison, we converted VAS pain scores reported on a 10 cm scale to a 100 mm scale by multiplying the scores by 10 (Adler 1998; Kuhn 1996; Zempsky 1997).

Details regarding the data extracted from each study can be found in Appendix 5 (Data extraction form).

 

Data analysis

The small number of trials in each comparison group and the heterogeneity of outcome measures precluded meta-analysis in the majority of comparisons. Therefore, we performed mostly a descriptive analysis. In the comparison of topical prilocaine-phenylephrine (PP) and topical tetracaine-epinephrine-cocaine (TAC), the reported outcomes (pain intensity measures) were statistically combinable and thus we pooled the data. Statistical calculations were computed with Review Manager (RevMan 5.1). We pooled patient self reported VAS scores (which are continuous outcomes) using the mean scores and SDs to derive a weighted mean difference (WMD) as well as the 95% confidence intervals (CIs). We computed a Chi2 test to test for heterogeneity. In the one statistically combinable comparison there was heterogeneity and thus we used a random-effects model for meta-analysis. However, if the diversity between trials would have been significant, then we planned to perform a descriptive analysis. It was planned to analyse dichotomous data using Review Manager (RevMan 5.1). Specifically, the relative risk would have been computed. However, due to the lack of relevant data in the included studies we did not analyse dichotomous data.

A subgroup analysis was intended to determine whether there were different results between adult and paediatric patients. We considered patients younger than 18 years old to be paediatrics and patients aged 18 years or older to be adults. However, subgroup analysis by age was not possible because of the small number of studies in each comparison group. Also, many trials included only paediatric or only adult patients. Moreover, the studies that included both adult and paediatric patients did not separately report outcomes according to the different age groups. We were unable to obtain the unreported data despite efforts to contact the study authors. No sensitivity analysis was intended or performed for this review.

 

Missing information

If necessary, an electronic mail or postal mail letter was sent to the contact author in order to acquire missing information. Additional data were sought from eight trials, but we were able to successfully obtain additional information from only one study (Smith 1997a). Furthermore, we contacted by electronic mail and received responses from two primary authors, Drs Amy Ernst and Gary Smith, regarding whether any of the patients' data may have been included in more than one of their studies (Ernst 1990; Ernst 1995a; Ernst 1995b; Ernst 1997; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a).

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

Independent review of the abstracts and titles identified by the electronic database searches yielded 39 potentially relevant studies. We obtained each of the 39 trials in full and examined them for possible inclusion in the review. Sixteen of the 39 retrieved trials did not meet the inclusion criteria. Furthermore, eight additional potentially relevant papers were identified, either through review of obtained study references (Bass 1990; Bonadio 1988a; Bonadio 1988b; Chipont 2001; Liebelt 1997; Peirluisi 1989; Yamamoto 1997) or manual searches of journals (Bonadio 1992). However, none of the eight papers met the inclusion criteria of the review. A detailed description of each of the 24 studies is provided in the Characteristics of excluded studies table. We were unable to locate any unpublished studies that qualified for the present review, despite direct communication with pertinent manufacturers and investigators. None of the 23 included trials were industry sponsored. A total of 23 RCTs met the inclusion criteria of this review. Detailed descriptions of each trial are provided in Characteristics of included studies. The detailed search results are found in Figure 1.

 FigureFigure 1. Search flow diagram

 

Participants

The trials included a total of 3128 adult and paediatric patients. Three trials included only adult participants (Ernst 1995b; Gaufberg 2007; White 1986). One trial enrolled only paediatric patients who were 10 years or younger (Schaffer 1985). Another trial was limited to children but the upper age limit was not specified (Bonadio 1990). The remaining 19 studies enrolled both adult and paediatric patients according to the definition provided above. The inclusion criteria applied in 10 of the retrieved trials potentially allowed children who were less than three years old to be enrolled (Anderson 1990; Blackburn 1995; Hegenbarth 1990; Pryor 1980; Schaffer 1985; Schilling 1995; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a). No duplicate patient data were included in the trials by Ernst or Smith (Ernst 1990; Ernst 1995a; Ernst 1995b; Ernst 1997; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a).

 

Wound closure

Wound closure was performed strictly with sutures in 21 studies. One study repaired lacerations with both sutures and staples (Krief 2002). Another trial repaired lacerations with skin staples in a minority (7%) of patients (Hegenbarth 1990). No alternative techniques of wound repair were employed. The lacerations were located on four anatomical regions: the face, scalp, extremities, and less commonly the trunk. All of the lacerations were superficial and the length of the dermal injuries ranged from less than 1.0 cm to 10.0 cm.

 

Topical anaesthetics

The 23 included RCTs studied a total of 18 different topical anaesthetics, which are listed in Appendix 6. Four studies had multiple arms that compared more than two different anaesthetic agents (Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a). Smith 1996 had six different groups, including five different topical anaesthetics and an infiltrated local anaesthetic arm. Smith 1997a evaluated two topical anaesthetics and infiltrated local anaesthetic. Smith 1997b compared four different topical anaesthetics and Smith 1998a studied three different topical agents.

Seventeen of the 23 studies compared different forms of topical anaesthetics and only a minority of trials contained arms with infiltrated local anaesthetic groups. Therefore, the main comparison was between the different topical preparations.

 

Outcome measures

The primary outcome measure was analgesic efficacy, reflected in the patient's self report of pain intensity during repair of the wound. Thirteen of the included trials determined anaesthetic efficacy through the participant's self report of pain intensity (Blackburn 1995; Ernst 1995a; Ernst 1995b; Ernst 1997; Gaufberg 2007; Kendall 1996; Krief 2002; Kuhn 1996; Smith 1996; Smith 1997b; Smith 1998a; White 1986; Zempsky 1997). Unless otherwise specified, discomfort was assessed during suturing or stapling. There were numerous tools that were used for patient self report of pain intensity. Ten studies used VAS pain scale scores (Ernst 1995b; Ernst 1997; Gaufberg 2007; Kendall 1996; Krief 2002; Kuhn 1996; Smith 1996; Smith 1997b; Smith 1998a; Zempsky 1997). Three RCTs used a faces pain scale (Blackburn 1995; Kendall 1996; Kuhn 1996). Furthermore, two trials used numerical pain ratings (0 to 10) (Ernst 1995a; White 1986).

Various secondary outcome measures were extracted from the RCTs. Nine trials provided observer-reported VAS pain scores (Ernst 1995b; Ernst 1997; Kendall 1996; Krief 2002; Kuhn 1996; Smith 1996; Smith 1997a; Smith 1998a; Zempsky 1997). Three studies used observer-rated Likert scores (Smith 1996; Smith 1997a; Smith 1997b). Two RCTs used observer-reported faces pain scales (Blackburn 1995; Kuhn 1996) and one study used an observer-rated multi-dimensional pain intensity scale (Ernst 1995a). Four trials calculated the percentage or absolute number of sutures eliciting pain (Bonadio 1990; Ernst 1995a; Ernst 1995b; Ernst 1997). Ten studies reported the requirement for supplemental lidocaine infiltration (Anderson 1990; Blackburn 1995; Ernst 1995a; Ernst 1997; Hegenbarth 1990; Krief 2002; Schaffer 1985; Vinci 1996; White 1986; Zempsky 1997). Seven RCTs assessed the effectiveness of anaesthesia by probing the laceration with a needle (Anderson 1990; Ernst 1990; Ernst 1997; Hegenbarth 1990; Kuhn 1996; Resch 1998; Schilling 1995). Seven trials included a verbal categorical scale to describe anaesthetic effectiveness (Pryor 1980; Resch 1998; Schaffer 1985; Schilling 1995; Smith 1996; Smith 1997b; Vinci 1996). Two studies employed an observer-reported compliance rating (Anderson 1990; Smith 1996) and two RCTs used an observer-rated acceptability of wound repair (Kendall 1996; Pryor 1980). Two studies reported the total number of topical anaesthetic doses (Gaufberg 2007; Vinci 1996). The following secondary outcome measures were each used by a single trial: the Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) (Kuhn 1996), observer numerical-rating of anaesthetic effectiveness (Ernst 1990), the Restrained Infants, Children Distress Rating Scale (RICDRS) (Smith 1996), and amount of anaesthetic used (Gaufberg 2007).

 

Adverse effects

Eleven trials explicitly assessed and reported the nature and incidence of topical local anaesthetic-related acute adverse effects (Blackburn 1995; Bonadio 1990; Ernst 1990; Ernst 1995a; Hegenbarth 1990; Kendall 1996; Kuhn 1996; Resch 1998; Schaffer 1985; Schilling 1995; Vinci 1996).

 

Risk of bias in included studies

We analysed the risk of bias in the 23 included trials by assessing randomization (sequence generation), blinding, allocation concealment and incomplete data outcome. Further information regarding risk of bias can be found in the 'Risk of bias' graph (Figure 2), summary (Figure 3) and tables (Characteristics of included studies).

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 3. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

We concluded that there was adequate, random sequence generation in six of the 23 trials (26%) (Ernst 1995a; Ernst 1995b; Ernst 1997; Resch 1998; Vinci 1996; Zempsky 1997) and insufficient information to make a judgement in nine of the studies (39%) (Ernst 1990; Gaufberg 2007; Krief 2002; Kuhn 1996; Schilling 1995; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a).

We concluded that participants and personnel were adequately blinded to the identity of the anaesthetic in 13 of 23 studies (57%) (Blackburn 1995; Bonadio 1990; Ernst 1990; Ernst 1995a; Ernst 1995b; Kuhn 1996; Resch 1998; Schaffer 1985; Schilling 1995; Smith 1996; Smith 1997a; White 1986; Zempsky 1997). There was insufficient information to confirm adequate blinding in four of the papers (17%) (Krief 2002; Smith 1997b; Smith 1998a; Vinci 1996). However, 13 of the 17 studies (76%) that compared different forms of topical anaesthetics were appropriately blinded. Seven of the eight trials that compared topical anaesthetics to infiltrated anaesthetic were not blinded (Anderson 1990; Ernst 1997; Gaufberg 2007; Hegenbarth 1990; Kendall 1996; Pryor 1980; Smith 1996). One trial (Smith 1997a) was adequately blinded because after the topical or local anaesthetic was administered, suturing procedures were videotaped. These videotapes were later reviewed by an observer who was completely blinded to which form of anaesthetic the patient had received.

We concluded that allocation was adequately concealed in five of the 23 studies (22%) (Blackburn 1995; Ernst 1995b; Kuhn 1996; Resch 1998; Schilling 1995) and unclear in six other studies (26%) (Ernst 1990; Krief 2002; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a).

Ten of the trials (43%) appropriately addressed incomplete data outcome (Anderson 1990; Ernst 1990; Ernst 1995a; Gaufberg 2007; Kendall 1996; Kuhn 1996; Pryor 1980; Schilling 1995; Vinci 1996; Zempsky 1997) and it was unclear in 12 studies (52%) (Blackburn 1995; Bonadio 1990; Ernst 1997; Hegenbarth 1990; Krief 2002; Resch 1998; Schaffer 1985; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a; White 1986).

 

Effects of interventions

See:  Summary of findings for the main comparison topical local anaesthetics compared to infiltrated local anaesthetics or other topical agents for repair of dermal lacerations

We first present the evidence regarding cocaine-containing topical anaesthetics. We included comparisons between cocaine-based topical anaesthetics and each of the following: a) infiltrated local anaesthetics; and b) different formulations of cocaine-based topical agents. Next, we summarize the evidence evaluating cocaine-free topical anaesthetics. We compared cocaine-free topical agents with each of the following: a) infiltrated local anaesthetics; b) formulations of cocaine-containing topical agents; and c) different formulations of cocaine-free topical anaesthetics. We also reported the data on acute anaesthetic-related adverse effects. A detailed and inclusive description of each of the 23 trials is provided in the table Characteristics of included studies.

 
(1) Evaluation of cocaine-containing topical anaesthetics

1a. Cocaine-containing topical anaesthetics versus local anaesthetic infiltration (six studies)

Six studies compared a topical cocaine-based agents with infiltrated local anaesthetic (see Appendix 7 for detailed study information). Five studies compared topical tetracaine-adrenaline-cocaine (TAC) with infiltrated local anaesthetic. Outcomes could not be mathematically combined because of the numerous different measures used to determine anaesthetic efficacy (Anderson 1990; Hegenbarth 1990; Pryor 1980; Smith 1996; Smith 1997a). The results regarding anaesthetic efficacy of topical TAC were inconsistent. Moreover, each of the trials either had a high risk of bias in multiple domains (Anderson 1990; Hegenbarth 1990; Pryor 1980) or unclear bias in three domains (Smith 1996; Smith 1997a). One study found topical adrenaline-cocaine (AC) to provide equivalent analgesia to local anaesthetic infiltration (Kendall 1996). However, the study was not blinded and there was a high risk of bias for both sequence generation and allocation concealment.

1b. Comparisons between different cocaine-containing topical anaesthetics (four studies)
Four studies compared topical tetracaine-adrenaline-cocaine (TAC) with another cocaine-based topical anaesthetic (Appendix 8). No significant difference in anaesthetic efficacy was found between TAC and either topical bupivacaine-adrenaline-cocaine (MAC) (Kuhn 1996) or adrenaline-cocaine (AC) (Bonadio 1990). Kuhn 1996 had unclear risk of bias for sequence generation but a low risk of bias for the other three key domains. Bonadio 1990 did not use a formal pain scoring scale to assess the efficacy of AC and there was a high risk of bias for both sequence generation and allocation concealment. Neither cocaine (C) (Ernst 1990) or tetracaine-cocaine (TC) (Vinci 1996) were found to be effective topical anaesthetics.

 
(2) Evaluation of cocaine-free topical anaesthetics

2a. Cocaine-free topical anaesthetics versus infiltrated local anaesthetic (four studies)
Four RCTs compared five different cocaine-free topical anaesthetics with infiltrated local anaesthetic (Appendix 9). Smith 1996 found no significant difference in VAS pain scores between infiltrated local anaesthetic and four different noradrenaline-containing topical anaesthetics, including bupivacaine-noradrenaline (BN), etidocaine-noradrenaline (EN), mepivacaine-noradrenaline (MN) and prilocaine-noradrenaline (PN). Smith 1997a also compared topical mepivacaine-noradrenaline (MN) with infiltrated local anaesthetic, but concluded that the later provided better analgesia. The two studies of topical MN could not be mathematically combined because of the heterogeneity in outcome measures, and Smith 1996 did not report standard deviations of the pain scores. Both of the trials by Smith and associates had an unclear risk of bias in at least three key domains. Also, in Smith 1996 the comparisons of infiltrated lidocaine and topical anaesthetics were not blinded. Moreover, Smith 1997a did not employ patient self-reported pain scoring scales, but instead provided observer estimates of pain.

No significant difference was found between infiltrated local anaesthetic and either topical lidocaine-adrenaline-tetracaine (LAT) (Ernst 1997) or topical lidocaine-epinephrine (TLE) (Gaufberg 2007). However, both of the trials were not blinded and did not appropriately conceal allocation.

2b. Cocaine-free topical anaesthetics versus cocaine-containing topical anaesthetics (11 studies)

Eleven trials compared 13 different cocaine-free topical anaesthetics with topical TAC (Appendix 10). Each of the studies employed TAC as the cocaine-containing topical preparation. Smith and associates published four papers relevant to this section (Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a). In comparisons confined to a single trial, Smith and associates found similar analgesic efficacy between topical TAC and each of the following topical agents: bupivacaine-noradrenaline (BN), prilocaine-noradrenaline (PN), tetracaine-lidocaine-phenylephrine (TLP) and tetracaine-phenylephrine (TP) (Smith 1996; Smith 1997b). Two papers compared topical prilocaine-phenylephrine (PP) with topical TAC (Smith 1997b; Smith 1998a). In  Analysis 1.1, the patient-reported VAS (100 mm) pain scores were pooled and no difference was found between topical PP and topical TAC (Figure 1) (WMD 5.56, 95% CI -2.20 to 13.32). There were conflicting conclusions from two studies regarding the efficacy of topical mepivacaine-noradrenaline (MN) (Smith 1996; Smith 1997a). The trials could not be statistically combined because different pain scoring scales were used to determine anaesthetic efficacy and Smith 1996 did not report the standard deviations of the outcomes. Each of the four trials by Smith and associates had unclear risk of bias for three or more key domains.

Three studies found similar efficacy between topical lidocaine-adrenaline-tetracaine (LAT) and TAC (Ernst 1995a; Ernst 1995b; Schilling 1995). We could not mathematically combine the results because of the heterogeneity in outcome measures. It was unclear whether Schilling 1995 used appropriate sequence generation but there was low risk of bias for the other domains. The two trials by Earnst and associates each had a high risk of bias for one key domain.

One RCT that did appropriately conceal allocation found no difference in pain scores in children anaesthetized with either EMLA cream (lidocaine 2.5% and prilocaine 2.5%) or topical TAC (Zempsky 1997). Another paper that probably did not have random sequence generation found no difference in the efficacy of topical lidocaine-adrenaline (LE) versus topical TAC (Blackburn 1995).

Topical TAC outperformed etidocaine-noradrenaline (Smith 1996), topical bupivacaine-phenylephrine (Smith 1998a), topical tetracaine-adrenaline (Schaffer 1985) and topical tetracaine (White 1986).

2c. Comparisons between different cocaine-free topical anaesthetics (five studies)
Five RCTs evaluated different cocaine-free topical anaesthetics (Appendix 11). Smith 1996 found no significant difference in anaesthetic efficacy between four different noradrenaline-containing topical anaesthetics, including bupivacaine-noradrenaline (BN), etidocaine-noradrenaline (EN), mepivacaine-noradrenaline (MN) and prilocaine-noradrenaline (PN). Another multi-armed RCT (Smith 1997b) demonstrated no significant difference between three different topical formulations that contained the vasoconstrictor phenylephrine, including prilocaine-phenylephrine (PP), tetracaine-phenylephrine (TP) and tetracaine-lidocaine-phenylephrine (TLP). A third trial by the same primary author concluded that there is similar efficacy between topical prilocaine-phenylephrine (PP) and bupivacaine-phenylephrine (BP) (Smith 1998a). Krief 2002 found no significant difference in pain scores in patients treated with either topical EMLA or LAT. Each of the papers by Smith and associates, as well as Krief 2002, had unclear risk of bias in at least three domains.

A fifth RCT, which had unclear assessment of incomplete data but otherwise was at low risk of bias, concluded that the solution and gel formulations of LAT provided comparable analgesic efficacy (Resch 1998).

 
(3) Anaesthetic related acute adverse effects

Approximately half of the included trials (12/23, enrolling 1713 patients) reported data regarding the incidence of potential anaesthetic-related acute adverse effects. Further details are displayed in  Summary of findings for the main comparison. There was only one reported episode of a local anaesthetic-related complication in any of the studies. In Vinci 1996, a single paediatric patient developed a large indurated, erythematous reaction one day after application of topical TAC. The skin reaction completely resolved with anti-histamine treatment and warm compresses. There were no other reported incidents of local anaesthetic-induced reactions or toxicity. Schaffer 1985 reported that only after being discharged home, 10.7% of children treated with TAC and 7.8% who received topical AC became drowsy or excitable. However, none of the symptoms occurred in the emergency department and there was no evidence that the symptoms were causally related to the topical anaesthetic. Two trials that included an infiltrated local anaesthetic group reported data on acute side effects (Hegenbarth 1990; Kendall 1996). None of the combined 256 participants administered local anaesthesia via infiltration in these two studies reported any adverse effects.

Ten different RCTs that studied cocaine-based topical anaesthetic explicitly reported information about acute adverse effects (Blackburn 1995; Bonadio 1990; Ernst 1990; Ernst 1995a; Hegenbarth 1990; Kendall 1996; Kuhn 1996; Schaffer 1985; Schilling 1995; Vinci 1996). The pooled data from these 10 trials resulted in an acute adverse reaction in 1/1042 patients (incidence 0.096%). This complication was not serious and is described previously. A total of five RCTs that used cocaine-free topical agents reported data on anaesthetic-related toxicity or side effects (Blackburn 1995; Ernst 1995a; Resch 1998; Schaffer 1985; Schilling 1995; Schilling 1995). None of the 358 patients in these five RCTs experienced any acute adverse reactions.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The present review consisted of a descriptive analysis. There were two predominant limitations that precluded meta-analysis. First, most of the comparisons between specific anaesthetic agents were confined to a single trial. Only in few instances were similar comparisons duplicated in subsequent studies. Moreover, the trials employed numerous different measures to determine anaesthetic efficacy. In fact, only 13 of the 23 included studies used a formal pain scale. The primary outcome measure was analgesic efficacy, reflected in the patient's self report of pain intensity during repair of the wound. We extracted surrogate pain scores provided by observers, however, non-concordance has been demonstrated between patients' and practitioners' assessments of procedure-related pain (Choiniere 1990; Singer 1999; Stephenson 1994). Therefore, during analysis we only considered surrogate pain scores in instances when patient-reported pain scales were not available.

Our systematic review addressed four principal questions regarding topically applied local anaesthetics for dermal laceration repair. First, we assessed whether the benefits of non-invasive, topical anaesthetic application occur at the expense of decreased analgesic efficacy. The data are from a single study that has unclear risk bias (Smith 1997a) and the remainder of the trials were at high risk of bias (Anderson 1990; Ernst 1997; Gaufberg 2007; Hegenbarth 1990; Kendall 1996; Pryor 1980; Smith 1996). Smith 1997a did not use patient self-reported pain scores to determine anaesthetic efficacy, but instead used observer-estimated pain scores. Therefore, there is a paucity of high quality studies, with low risk of bias, to make definitive conclusions regarding the efficacy topical anaesthetics versus infiltrated local anaesthesia. Future research using well designed RCTs is necessary to answer this question.

Our second objective was to compare the efficacy of various single or multi-component topical anaesthetic agents for repair of dermal lacerations. The data are from studies that have either unclear risk of bias (Ernst 1990; Kuhn 1996; Schilling 1995; Smith 1996; Smith 1997a; Smith 1997b; Smith 1998a) or high risk of bias (Blackburn 1995; Bonadio 1990; Ernst 1995a; Ernst 1995b; Schaffer 1985; Vinci 1996; White 2004; Zempsky 1997). We have summarized the findings of individual trials in Appendix 8; Appendix 10; and Appendix 11. However, the evidence contains bias that may cause some doubt about the findings, or even significantly weaken the results.

The third objective was to determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Thirteen RCTs were included in the review, which assessed the effectiveness of cocaine-free topical anaesthetics. None of the studies were at low risk of bias. Data from two studies were mathematically combined and found topical prilocaine-phenylephrine (PP) to provide effective analgesia (Smith 1997b; Smith 1998a). However, both of the studies had unclear risk of bias for each key domain and therefore there is some uncertainty about the results. Additional formulations of topical cocaine-free anaesthetics were assessed only in a single RCT. Results from the papers with unclear risk of bias found that the following agents may provide effective topical analgesia: lidocaine-adrenaline-tetracaine (LAT) (Schilling 1995), bupivacaine-noradrenaline (BN) (Smith 1996), prilocaine-noradrenaline (PN) (Smith 1996), tetracaine-lidocaine-phenylephrine (TLP) (Smith 1997b), tetracaine-phenylephrine (TP) (Smith 1997b) and lidocaine-prilocaine (EMLA) (Krief 2002). Topical LAT, which exploits the rapid onset of lidocaine and long duration of tetracaine (Altman 1985), has been the most widely studied cocaine-free formulation. However, before definitive conclusions can be made, additional investigation is warranted with trials that are well designed and assess anaesthetic efficacy with validated patient self-reported pain scoring scales.

Finally, we evaluated the safety of both cocaine-containing and cocaine-free topical anaesthetics. Many of the included trials (12 of 23) reported data regarding the incidence of potential anaesthetic-related acute adverse effects. Only one study reported a topical local anaesthetic-related side effect (Vinci 1996). The reaction consisted of a large indurated, erythematous reaction that occurred after topical application of TAC. No serious complications, such as seizures or anaphylactic reactions, were reported in any of the trials. Although the reported data is insufficient to determine the exact incidence of complications, if topical anaesthetics are applied as directed and appropriately dosed then serious adverse effects are probably infrequent. The combined observations from 10 trials that administered cocaine-based agents and explicitly reported data on side effects resulted in one adverse reaction out of 1042 total patients (incidence 0.096%). Six studies that administered cocaine-free anaesthetics agents reported data on toxicity and none of the 418 patients in this group experienced acute adverse reactions.

There are sources of potential bias in the review. The primary outcome was patients' self report of pain intensity during repair of the wound, using validated pain scales. However, a significant number of included trials used observer-reported pain scores or other elementary surrogate outcomes to determine anaesthetic efficacy. Non-concordance has been demonstrated between patients' pain scores and ratings by physician, parents or other proxies (Choiniere 1990; Singer 1999; Stephenson 1994). Moreover, 20 of the included 23 RCTs enrolled paediatric patients and the evaluation of pain in children can be challenging. Several pain scales, including the VAS and faces scale, have been used in a reliable and validated manner in children as young as five years (Berde 1991; Lander 1993; Zeltzer 1991). Also, there is evidence supporting the validity of tools for measuring acute pain in children as young as three years old (Tyler 1993). However, the lower age limit at which children can credibly quantify pain intensity is controversial (Tyler 1993) and there is a need to validate the behavioural pain scales for early verbal and pre-verbal children (Crellin 2007). Therefore, we cannot exclude the possibility that pain assessment in younger paediatric patients may not be accurate.

The present review is limited to repair of dermal lacerations. Therefore, the results may not be generalizable to repair of wounds located on mucosal surfaces. Also, the dermis provides a barrier to penetration of topical anaesthetic, and so our findings may not be applicable to instrumentation of intact skin.

In conclusion, based on mostly descriptive analysis, topical anaesthetics may in fact be an efficacious, non-invasive means of providing analgesia prior to suturing of dermal lacerations. However, the data regarding the efficacy of each topical anaesthetic are mostly based upon single comparisons in trials that have unclear or high risk of bias. In order to make definitive conclusions, additional methodologically well designed studies with low risk of bias are necessary. Future research should focus on the efficacy of cocaine-free anaesthetics in light of the burdens of dispensing cocaine, a controlled substance that is widely abused.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

Injection of anaesthetics per se induces discomfort, and may worsen 'needle anxiety' in paediatric participants and distort the wound site (Kundu 2002). Therefore, topical anaesthetics are preferable if they do in fact provide similar analgesia to injected local anaesthetics. There is a suggestion from individual studies that some topical formulations may have similar efficacy to conventional local anaesthetics. However, because of methodological heterogeneity and a lack of high quality trials, definitive conclusions for clinical practice cannot be made. 

If cocaine-free topical anaesthetics have similar effectiveness as cocaine-containing agents then the latter can no longer be justified in light of their high cost and potential adverse effects. Topical lidocaine-adrenaline-tetracaine (LAT), which exploits the rapid onset of lidocaine and the long duration of tetracaine, has been the most widely studied cocaine-free formulation. However, additional studies with sound methodological design are necessary before drawing definitive conclusions for clinical practice.

No serious complications were reported in any of the patients treated with either cocaine-based or cocaine-free topical anaesthetics. One mild, self-limiting skin reaction did occur in one case after application of topical TAC. Nevertheless clinicians should exhibit caution and apply topical formulations only as directed, avoid mucous membrane contact and follow appropriate dosing regimens.

 
Implications for research

More investigation is warranted to compare topical lidocaine-adrenaline-tetracaine (LAT) with the other potentially efficacious, cocaine-free topical anaesthetics such as bupivacaine-noradrenaline (BN), prilocaine-phenylephrine (PP) or tetracaine-lidocaine-phenylephrine (TLP). Also, future research could determine additional clinically useful topical local anaesthetics or combinations.

Furthermore, there is a need for additional methodologically sound studies that are less likely to be flawed by bias or confounding variables. Many of the included trials did not determine analgesic efficacy with validated, patient self-reported pain scales, but instead used observer-reported pain scores or other elementary surrogate measures. Future trials should adopt uniform outcomes using the patient's own assessments of procedure-related pain intensity. It is young children that may benefit most from non-invasive, effective topical anaesthesia prior to laceration repair. Therefore, validated behavioral pain and distress scales for pre-verbal or early verbal children will facilitate the study of the efficacy and safety of topical anaesthetics in this patient subgroup.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

We would like to thank Mathew Zacharias, Marialena Trivella, Ronan O’Sullivan, Stephen Priestley, Sujesh Bansal and Nete Villebro for for their help and editorial advice during the preparation of the systematic review.

We would also like to thank Mathew Zacharias, André Muller, Stephen Priestley, Janet Wale, Kathie Godfrey, Nete Villebro and Jane Cracknell for their help and editorial advice during the preparation of the protocol for the systematic review. We also acknowledge the efforts of Karen Hovhannisyan, Catherine Guarcello, Marybeth Edwards, Richard Kammer and Dr Morton Rosenberg for assistance with the literature search, Dr. Joseph Lau with advise with statistics, and Dr. Mukhtar Zaidi for pharmacological consultation.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Topical prilocaine-phenylephrine (PP) versus topical tetracaine-epinephrine-cocaine (TAC)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient self-reported VAS (0-100 mm) pain scores2240Mean Difference (IV, Random, 95% CI)5.59 [-2.16, 13.35]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. Search strategy for CENTRAL, the Cochrane Library

#1 MeSH descriptor Lacerations, this term only
#2 MeSH descriptor Wounds and Injuries, this term only
#3 MeSH descriptor Facial Injuries explode all trees
#4 MeSH descriptor Finger Injuries explode all trees
#5 MeSH descriptor Wounds, Penetrating explode all trees
#6 MeSH descriptor Hand Injuries explode all trees
#7 MeSH descriptor Sutures explode all trees
#8 MeSH descriptor Surgical Stapling explode all trees
#9 (laceration* or wound* or suture or stapling or repair*):ti,ab
#10 ((facial or dermal or cutaneous or finger or hand or eyelid) near injur*):ti,ab
#11 (penetrat* near wound*)
#12 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11)
#13 (topical near (an?esthe* or lidocain* or lignocain* or tetracain* or amethocain* or benzocain* or butamben or dibucain* or pramoxin* or prilocain* or etidocian))
#14 emla* or (eutectic mixture of local an?esthe*) or (tetracaine?adrenaline?cocain*) or (tetracaine?epinephrine?cocain*) or (lidocaine?adrenaline?tetracain*) or (lidocaine?epinephrine?tetracain*) or (spray or ointment or gel or cream or lotion or jelly or balm):ti,ab
#15 MeSH descriptor Administration, Topical, this term only
#16 MeSH descriptor Ointments, this term only
#17 MeSH descriptor Gels, this term only
#18 (#13 OR #14 OR #15 OR #16 OR #17)
#19 (#12 AND #18)

 

Appendix 2. Search strategy for MEDLINE(Ovid SP)

1. laceration.mp. or exp lacerations/ or exp facial Injuries/ or exp finger injuries/ or exp wounds, penetrating/ or exp hand injuries/ or exp sutures/ or exp surgical stapling/ or ((wounds.mp. or exp wounds/) and injuries/) or (injury adj3 (hand or eyelid or finger or facial or dermal)).mp. or cutaneous.mp. or staple.mp. or repair.mp.
2. (topical adj3 (an?esthe* or lidocaine or lignocaine or lidoderm or tetracaine or amethocaine or benzocaine or butamben or pramoxine or prilocaine or topical)).mp. or exp administration, topical/ or topical.ti,ab.or emla.mp.or eutectic mixture of local an?esthe*.mp. or tetracaine-adrenaline-cocaine.mp. or tetracaine-epinephrine-cocaine.mp. or lidocaine-adrenaline-tetracaine.mp. or lidocaine-epinephrine-tetracaine.mp. or spray.ti,ab. or ointment.mp. or exp ointments/ or gel.mp. or exp gels/ or cream.mp. or lotion.mp. or jelly.mp. or balm.mp.
3. 1 and 2
4. ((randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti.) not (animals not (humans and animals)).sh.
5. 3 and 5

 

Appendix 3. Search strategy for CINAHL (EBSCO host)

S28 S20 and S27
S27 S21 or S22 or S23 or S24 or S25 or S26
S26 AB random* or controlled trial* or mulicenter or placebo*
S25 (MM "Multicenter Studies")
S24 (MH "Prospective Studies+")
S23 (MM "Double-Blind Studies") or (MM "Single-Blind Studies") or (MM "Triple-Blind Studies")
S22 (MM "Placebos")
S21 (MM "Random Assignment") or (MH "Clinical Trials+")
S20 S12 and S19
S19 S13 or S14 or S15 or S16 or S17 or S18
S18 AB emla* or (eutectic mixture of local an?esthe*) or (tetracaine?adrenaline?cocain*) or (tetracaine?epinephrine?cocain*) or (lidocaine?adrenaline?tetracain*) or (lidocaine?epinephrine?tetracain*)
S17 AB spray or ointment or gel or cream or lotion or jelly or balm
S16 AB ( an?esthe* or lidocain* or lignocain* or tetracain* or amethocain* or benzocain* or butamben or dibucain* or pramoxin* or prilocain* or etidocian* ) and topical
S15 (MH "Gels")
S14 (MH "Ointments")
S13 (MH "Administration, Topical")
S12 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11
S11 AB laceration* or wound* or injur* or stapl* or repairor or suture*
S10 AB penetrat* and AB wound*
S9 AB ( facial or dermal or cutaneous or finger or hand or eyelid ) and AB injur*
S8 (MH "Surgical Stapling")
S7 (MH "Sutures")
S6 (MH "Hand Injuries")
S5 (MH "Finger Injuries")
S4 (MH "Arm Injuries")
S3 (MH "Facial Injuries")
S2 (MH "Wounds and Injuries+") or (MH "Wounds, Penetrating+")
S1 (MH "Tears and Lacerations")

 

Appendix 4. Search strategy for EMBASE (Ovid SP)

1. exp laceration/ or injury/ or exp face-injury/ or exp finger-injury/ or exp hand-injury/ or exp suture/ (123072)
2. (laceration* or wound* or injur* or ((facial or dermal or cutaneous or finger or hand or eyelid) adj3 injur*)).ti,ab. or (penetrat* adj3 wound*).mp. or (stapl* or repairor or suture*).ti,ab.
3. 1 or 2
4. (topical adj3 (an?esthe* or lidocain* or lignocain* or tetracain* or amethocain* or benzocain* or butamben or dibucain* or pramoxin* or prilocain* or etidocian)).mp.
5. (emla* or eutectic mixture of local an?esthe* or tetracaine?adrenaline?cocain* or tetracaine?epinephrine?cocain* or lidocaine?adrenaline?tetracain* or lidocaine?epinephrine?tetracain*).mp.
6. (spray or ointment or gel or cream or lotion or jelly or balm).ti,ab.
7. topical-drug-administration/ or ointment/ or gel/
8. 6 or 4 or 7 or 5
9. 8 and 3
10. (placebo.sh. or controlled study.ab. or random*.ti,ab. or trial*.ti,ab.) not (animals not (humans and animals)).sh.
11. 10 and 9

 

Appendix 5. Data Extraction Form


First authorJournal/Conference Proceedings etcYear

 

 
  



 


Trial characteristics

 Further details

RCT/Quasi 

Study size (number of patients) 

Setting of study (single versus multi-centre, inpatient versus outpatient) 



  


Participant characteristics

 Further details

Age (mean, median, range, etc) 

Sex of participants (numbers, percentages) 

Wound characteristics(length, location of laceration, etc.) 



  


Anaesthetic characteristics

 Further details

Infiltratedanaesthetics (agent, dosage) 

Topical anaesthetics (agent, dosage, duration of application) 

Were systemic analgesics or sedatives given? 



 


Outcomes

 Further details

Primary measure of pain intensity (patient self-report using pain scale such as VAS, numerical rating, etc) 

Secondary measure of pain intensity (incidence of topical anaesthetic failure, requirement of supplemental anaesthesia, patient behavioural responses etc) 

Anaesthetic related toxicity or acute adverse events 



 

 

Methodological quality

 


Sequence Generation

State here method used to generate sequence and reasons for gradingGrade (circle)

 

 
Low risk

High risk

Unclear



 

 


Allocation Concealment

State here method used to conceal allocation and reasons for gradingGrade (circle)

 

 
Low risk

High risk

Unclear



 

 


Blinding

State here method used to blind study and reasons for gradingGrade (circle)

 

 
Low risk

High risk

Unclear



  


Description of Withdrawals and Dropouts

State here method used to address incomplete outcome dataGrade (circle)

 

 
Low risk

High risk

Unclear



  

 

 

Appendix 6. Local anaesthetics and vasoconstrictors including alternative names

COCAINE CONTAINING TOPICAL ANAESTHETICS

AC = Epinephrine-cocaine or Adrenaline-cocaine

C = Cocaine

MAC = Bupivacaine- epinephrine-cocaine or Bupivacaine-adrenaline-cocaine

TAC = Tetracaine-epinephrine-cocaine or Tetracaine adrenaline-cocaine

TC = Tetracaine Cocaine

COCAINE FREE TOPICAL ANAESTHETICS

BN = Bupivacaine-norepinephrine

EMLA = Eutectic mixture of local anaesthetics = lidocaine-prilocaine

EN= Etidocaine-norepinephrine

LAT = LET = Lidocaine-epinephrine-tetracaine or Lidocaine-adrenaline-tetracaine

LE = lidocaine-epinephrine or Lidocaine-adrenaline

MN= Mepivacaine-norepinephrine

PN = Prilocaine-norepinephrine

PP = Prilocaine-phenylephrine

T = Tetracaine

TE = Tetracaine-epinephrine or Tetracaine-adrenaline

TP = Tetracaine-phenylephrine

TLP = Tetracaine-lidocaine-phenylephrine

ALTERNATIVE NAMES TO LOCAL ANAESTHETICS AND VASOCONTRICTORS

Epinephrine is the same as adrenaline

Bupivacaine also called marcaine or sensorcaine

Lidocaine also called xylocaine

 

Appendix 7. Cocaine-containing topical anaesthetics versus infiltrated local anaesthetics


StudyAnaestheticsPatient self-reported pain scoresSecondary outcome measuresIncidence anaesthetic toxicity

Anderson 1990Topical tetracaine-epinephrine-cocaine (TAC) vs infiltrated lidocaineNone1) Adequate initial anaesthesia (TAC = 89% vs infiltrated local anaesthetic = 79%, P=non-significant)
2) Physician compliance scale (1=complete compliance to 4=continuous resistance) (mean score ± SD: TAC = 1.25 ± 0.57 vs infiltrated local anaesthetic = 1.94 ± 1.12, P<0.002).
3) Requirement of supplemental lidocaine infiltration (topical TAC = 18% vs infiltrated local anaesthetic = 23%, P=non-significant).
Not reported

Hegenbarth 1990Topical TAC vs infiltrated lidocaineNone1) Adequate initial anaesthesia for facial and scalp lacerations (topical TAC = 81% vs infiltrated local anaesthetic = 87%, P=0.005). Adequate initial anaesthesia for the extremity and trunk wounds (topical TAC = 43% vs infiltrated local anaesthetic = 89%, P<0.0001)0/467

Pryor 1980Topical TAC vs infiltrated lidocaineNone1) Verbal rating of anaesthetic efficacy (complete: TAC = 84% vs infiltrated local anaesthetic = 88%, P=not reported).
2) Anaesthetic acceptability: patients 17 years or younger preferred topical TAC (P<0.005), there was no difference between the two anaesthetic groups in patients older then 17 years
Not reported

Smith 1996Topical TAC vs infiltrated lidocainePatient-reported VAS (100mm) pain scores (mean scores: topical TAC = 12.0 versus infiltrated local anaesthetic = 26.3, P=NS)1) Observer-reported VAS pain scores
2) Observer-reported Likert pain scores
3) Oberver-rated Restrained Infants and Children Disress Rating Scale
4). Suture technician-rated anaesthetic effectiveness
Not reported

Smith 1997aTopical TAC vs infiltrated lidocaineNone1) Observer-reported VAS pain scores (suture technicians, research assistants, video-tape reviewers)

2) Observer-reported Lickert (1-7) pain scores (parent, suture technicians)

3) Requirement for supplemental lidocaine infiltration

(See Characteristics of included studies for data)
Not reported

Kendall 1996Topical (epinephrine-cocaine) AC vs infiltrated lidocaineThe study pooled patient-reported VAS and Wong-Baker faces pain scores (mean score: topical AC = 4.50 vs infiltrated local anaesthetic = 4.40, P=NS)1) Physician-rated VAS pain scores
2) Parent-rated VAS scores
3) Parent's rating of overall acceptability of procedure
0/107



 

Appendix 8. Comparisons between different cocaine-containing topical anaesthetics


StudyTopical AnaestheticsPatient self-reported pain scoresSecondary outcome measuresIncidence anaesthetic toxicity

Kuhn 1996Bupivacaine- adrenaline-cocaine (MAC) vs tetracaine- epinephrine-cocaine (TAC)1) In children < 12 years: Wong-Baker faces (1-9) scale (mean score ± SD: topical MAC = 2.35 ± .50 vs topical TAC = 2.46 ± 2.34, P=0.96)

2) Patients 12 years or older: VAS (100 mm) pain scale (mean score ± SD: topical MAC = 6.9 ± 10.9 vs topical TAC = 12.0 ± 14.5, P=0.16)
1) Adequacy of initial anaesthesia

2) Patients preference for topical anaesthesia in the future
0/180

Bonadio 1990TAC vs adrenaline-cocaine (AC)None1) Physician calculated the total number of "sutures eliciting pain" (topical AC = 7/103 (4%) vs topical TAC = 7/151 (7%), P= not-reported).0/55

Ernst 1990TAC vs cocaine (C)None1) Incidence of "poor anaesthesia" (topical cocaine = 20% vs topical TAC = 12%, P=not-reported)

2) Physician numerical rating of anaesthetic effectiveness (0=least effective to 10=most effective) (mean scores ± SD: topical cocaine = 6.44 ± 3.48 vs topical TAC = 7.74 ± 3.03, P=0.005).
0/139

Vinci 1996TAC (two different strengths) vs tetracaine-cocaine (TC)NoneTopical TAC 1 vs topical TC:
1) Complete anaesthesia (TAC 1 = 73% vs TC = 28%, P<0.001).

2) Requirement second dose of topical anaesthetic (TAC 1 = 30% vs topical TC = 66%, P<0.003).

3) Requirement for supplemental lidocaine infiltration (TAC 1 = 6% vs topical TC = 9%, P=not reported)

Topical TAC 2 vs topical TC:
1) Complete anaesthesia (TAC 2 = 63% vs TC = 28%, P<0.001)

2) Requirement second dose of topical anaesthetic (TAC 2 = 46% vs TC = 66%, P<0.003)

3) Requirement for supplemental lidocaine infiltration (TAC 2 = 2% vs TC = 9%, P=not reported)
1/156 (erythematous rash one day after application of standard topical TAC)



 

Appendix 9. Cocaine-free topical anaesthetics versus infiltrated local anaesthetics


StudyAnaestheticsPatient self-reported pain scoresSecondary outcome measuresIncidence anaesthetic toxicity

Ernst 1997Topical lidocaine-epinephrine-tetracaine (LAT) vs infiltrated lidocaineVAS (100mm) pain scores (median values: topical LAT = 0 vs infiltrated local anaesthetic = 0, P=0.48)1) Physician-rated VAS pain scores

2) Requirement supplemental lidocaine infiltration

3) Percentage painful sutures
Not reported

Gaufberg 2007Topical lidocaine-epinephrine (LE) vs infiltrated lidocaineVAS (100mm) pain scores (mean score ± SD: topical TLE = 0.16 ± 0.46 versus infiltrated lidocaine = 0.20 ± 0.49, P=0.59).1) Amount of lidocaine required (mg)

2) Total number of topical anaesthetic applications
Not reported

Smith 1996Topical bupivacaine-norepinephrine (BN), topical etidocaine-norepinephrine (EN), topical mepivacaine-norepinephrine (MN) and topical prilocaine-norepinephrine (PN) vs infiltrated lidocaineVAS (100 mm) pain scores (mean scores: BN = 18.3, EN = 46.5, MN = 27.0, PN = 36.0 vs infiltrated anaesthetic = 26.3, standard deviations not reported)

(no significant difference between any of the cocaine free topical agents and infiltrated lidocaine)
1) Observer reported VAS pain scores

2) Observer reported Likert pain scores

3) Oberver-rated Restrained Infants and Children Disress Rating Scale

4) Suture technician-rated anaesthetic effectiveness
Not reported

Smith 1997aTopical mepivacaine-norepinephrine (MN) vs infiltrated lidocaineNone1) Observer reported VAS pain scales scores

2) Observer reported Lickert pain scores

3) Requirement for supplemental lidocaine infiltration

(See characteristics of included studies for data)
Not reported



 

Appendix 10. Cocaine-free topical anaesthetics versus cocaine-containing topical anaesthetics


StudyTopical AnaestheticsPatient self-reported pain scoresSecondary outcome measuresIncidence anaesthetic toxicity

Smith 1996Bupivacaine-norepinephrine (BN), etidocaine-norepinephrine (EN), mepivacaine-norepinephrine (MN) and prilocaine-norepinephrine (PN) vs tetracaine-epinephrine-cocaine (TAC)Patient-reported VAS (100 mm) pain scores (mean scores: BN = 18.3, EN = 46.5, MN, PN = 36.0 vs TAC = 12.0, standard deviations not reported)

(TAC significantly outperformed EN; no significant difference between any other groups)
1) Observer reported VAS and Likert pain scale scores

2)Observer-rated Restrained Infants and Children Disress Rating Scale

3) Suture technician-rated anaesthetic effectiveness
Not reported

Smith 1997aMepivacaine-norepinephrine (MN) vs
TAC
None1) Observer-reported VAS pain scores (suture technicians, research assistants, video-tape reviewers)

2) Observer-reported Lickert (1-7) pain scores (parent, suture technicians)

3) Requirement for supplemental lidocaine infiltration

(See characteristics of included studies for data)
Not reported

Smith 1997bPrilocaine-phenylephrine (PP),
tetracaine-phenylephrine (TP) and
tetracaine-lidocaine-phenylephrine (TLP) vs TAC
VAS (100 mm) pain scores (mean score ± SD: PP = 29.0 ± 43.4, TP = 24.2 ± 37.2, TLP = 30.6 ± 40.3 versus TAC = 17.6 ± 34.1 (No significant difference between groups, P=0.5)1) Oberver-reported VAS (100 mm) pain scores

2) Oberver-reported Likert (1-7) pain scores

3) Suture technicians-rated the anaesthetic effectiveness
Not reported

Smith 1998aPrilocaine-phenylephrine (PP) and bupivacaine-phenylephrine (BP) vs TACVAS (100 mm) pain scores (mean score ± SD: PP = 21.0 ± 28.0 and BP = 41.0 ± 35.0 vs TAC = 18.0 ± 24.0). (No difference reported between groups, P=0.07)Observer-reported VAS pain scores (suture technicians, research assistants and parents)Not reported

Ernst 1995aLAT vs TACModified multidimensional pain scale (0-10) (mean ranked sum: LAT = 49.0 vs TAC = 46.9, P=0.71)1) Physician-rated modified multidimensional pain scale (0-10)

2) Percentage of sutures causing pain

3) Requirement of supplemental lidocaine infiltration
0/95

Ernst 1995bLAT vs TACVAS (100 mm) pain scores (mean ranked sum: LET = 45.3 vs TAC = 50.8, P=0.27)1) Physician-reported VAS scores

2) Percentage of sutures causing pain
Not reported

Schilling 1995LAT vs TACNone1) Adequacy of initial anaesthesia (LAT = 74.4% vs TAC = 79.5%, P=0.46)

2) Anaesthetic effectiveness (complete anaesthesia: LAT = 82.4% vs topical TAC = 75.9%, P=0.18)
0/151

Zempsky 1997Lidocaine-prilocaine (EMLA) vs TACVAS (100 mm) pain scores (mean score ± SD: EMLA = 46.0 ± 26.0 vs TAC = 40.0 ± 25.0, P=0.50)1) Observer-rated VAS pain scores

2) Requirement for supplemental lidocaine infiltration
Not reported

Blackburn 1995Lidocaine-epinephrine (LE) vs TACFaces pain scale (1-9) scores (mean score ± SD: LE = 3.29 ± 1.92 vs TAC = 2.66 ± 1.78, P=0.33).Requirement for supplemental lidocaine infiltration0/35

Schaffer 1985Tetracaine-epinephrine (TA) vs TAC)None1) Physician-rating of anaesthetic effectiveness (complete anaesthesia: TA = 47.1% vs TAC = 75%, P<0.05)

2) Requirement of rescue lidocaine infiltration (TA = 27.5% vs TAC = 8.9%, P=0.01)
0/107

White 1986Tetracaine (T) vs TACNumerical pain scale (0-10) score (mean scores: tetracaine = 5.6 vs TAC = 3.53, P<0.05, standard deviations not reported)Requirement of supplemental lidocaine infiltrationNot reported



 

Appendix 11. Comparisons between different cocaine-free topical anaesthetics


StudyTopical AnaestheticsPatient self-reported pain scoresSecondary outcome measuresIncidence anaesthetic toxicity

Smith 1996Bupivacaine-norepinephrine (BN) vs etidocaine-norepinephrine (EN) vs mepivacaine-norepinephrine (MN) vs prilocaine-norepinephrine (PN)Patient-reported VAS (100 mm) pain scores (mean scores: topical BN = 18.3 vs topical EN = 46.5 vs topical MN = 27.0 vs topical PN = 36.0) (no significant difference between any of cocaine free topical groups).1) Observer reported VAS and Likert pain scale scores

2)Observer-rated Restrained Infants and Children Disress Rating Scale

3) Suture technician-rated anaesthetic effectiveness
Not reported

Smith 1997bPrilocaine-phenylephrine (PP) vs
tetracaine-phenylephrine (TP) vs
tetracaine-lidocaine-phenylephrine (TLP)
VAS (100 mm) pain scores (mean score ± SD: PP = 29.0 ± 43.4 vs TP = 24.2 ± 37.2 vs TLP = 30.6 ± 40.3 (No significant difference between groups, P=0.5)1) Oberver-reported VAS (100 mm) pain scores

2) Oberver-reported Likert (1-7) pain scores

3) Suture technicians-rated the anaesthetic effectiveness
Not reported

Smith 1998aPrilocaine-phenylephrine (PP) vs bupivacaine-phenylephrine (BP)VAS (100 mm) pain scores (mean score ± SD: topical PP = 21.0 ± 28.0 vs topical BP = 41.0 ± 35.0, P=0.07)Observer-reported VAS pain scores (suture technicians, research assistants and parents)Not reported

Krief 2002Lidocaine-prilocaine (EMLA) vs lidocaine-epinephrine-tetracaine (LAT)VAS (100 mm) pain scores were not significantly different between the two groups (mean pain scores not provided, P > 0.05)1) Observer-reported VAS pain scores (legal guardian and physician)

2) Requirement of supplemental lidocaine infiltration
Not reported

Resch 1998Topical LAT gel vs LAT solutionNone1) Adequacy of initial anaesthesia (adequate anaesthesia: LAT solution = 84% vs LAT gel = 82%, P>0.05)

2) Effectiveness of anaesthesia (complete anaesthesia: LAT solution = 76% vs LAT gel = 85%, P=0.007)
0/194



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 22 March 2011.


DateEventDescription

31 May 2012AmendedContact details updated.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 3, 2005
Review first published: Issue 6, 2011


DateEventDescription

17 April 2012AmendedContact details updated.

18 January 2012AmendedContact details updated.

1 September 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Conceiving the review: Daniel Carr (DC)
Co-ordinating the review: Anthony Eidelman (AE) and DC
Undertaking manual searches: AE and Ikay Enu (IE)
Screening search results: AE, Cristy Baldwin (CB), IE
Organizing retrieval of papers: AE, IE and Jocelyn Weiss (JW)
Screening retrieved papers against inclusion criteria: AE, CB, IE, and JW
Appraising quality of papers: AE, CB
Abstracting data from papers: AE, CB, IE
Writing to authors of papers for additional information: AE
Providing additional data about papers: AE, IE
Obtaining and screening data on unpublished studies: AE
Data management for the review: AE, IE, Ewan McNicol (EM)
Entering data into Review Manager (RevMan 5.1 ): AE, EM
RevMan statistical data: AE
Other statistical analysis not using RevMan: AE
Double entry of data: (data entered by person one: AE; data entered by person two: EM)
Interpretation of data: AE, CB, EMand DC
Statistical analysis: AE
Writing the review: AE, DC
Securing funding for the review: DC
Performing previous work that was the foundation of the present study: AE, IE, JW, DC
Guarantor for the review (one author): AE
Responsible for reading and checking review before submission: AE and DC

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

None known

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • Evenor Armington Fund, USA.
  • Saltonstall Fund, USA.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The title was changed from 'Topical anaesthetics for repair of torn skin' to 'Topical anaesthetics for repair of dermal laceration'

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Anderson 1990 {published data only}
Blackburn 1995 {published data only}
  • Blackburn PA, Butler KH, Hughes MJ, Clark MR, Riker RL. Comparison of tetracaine-adrenaline-cocaine (TAC) with topical lidocaine-epinephrine (TLE): efficacy and cost. American Journal of Emergency Medicine 1995;13(3):315-7. [MEDLINE: 7755827]
Bonadio 1990 {published data only}
  • Bonadio WA, Wagner V. Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children. Pediatrics 1990 1990;86(6):856-57. [MEDLINE: 2251022]
Ernst 1990 {published data only}
Ernst 1995a {published data only}
  • Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT. Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics 1995;95(2):255-8. [MEDLINE: 7838644]
Ernst 1995b {published data only}
  • Ernst AA, Marvez-Valls E, Nick TG, Weiss SJ. LAT (lidocaine-adrenaline-tetracaine) versus TAC (tetracaine-adrenaline-cocaine) for topical anesthesia in face and scalp lacerations. American Journal of Emergency Medicine 1995;13(2):151-4. [MEDLINE: 7893297]
Ernst 1997 {published data only}
  • Ernst AA, Marvez-Valls E, Nick TG, Mills T, Minvielle L, Houry D. Topical lidocaine adrenaline tetracaine (LAT gel) versus injectable buffered lidocaine for local anesthesia in laceration repair. Western Journal of Medicine 1997;167(2):79-81. [MEDLINE: 9291744]
Gaufberg 2007 {published data only}
  • Gaufberg SV, Walta MJ, Workman TP. Expanding the use of topical anesthesia in wound management: sequential layered application of topical lidocaine with epinephrine. The American Journal of Emergency Medicine 2007;25(4):379-84. [MEDLINE: 17499653]
Hegenbarth 1990 {published data only}
  • Hegenbarth MA, Altieri MF, Hawk WH, Greene A, Ochsenschlager DW, O'Donnell R. Comparison of topical tetracaine, adrenaline, and cocaine anesthesia with lidocaine infiltration for repair of lacerations in children. Annals of Emergency Medicine 1990;12(1):63-7. [MEDLINE: 2297157]
Kendall 1996 {published data only}
  • Kendall JM, Charters A, McCabe SE. Topical anaesthesia for children's lacerations: an acceptable approach?. Journal of Accident and Emergency Medicine 1997;14(1):119-22. [MEDLINE: 8653235]
Krief 2002 {published data only}
  • Krief W, Sadock V, Tunik M, Mojica M, Manikian A. EMLA vs LET for topical anesthesia in wound repair. Academic Emergency Medicine 2002;9(5):398.
Kuhn 1996 {published data only}
Pryor 1980 {published data only}
Resch 1998 {published data only}
  • Resch K, Schilling C, Borchert BD, Klatzko M, Uden D. Topical anesthesia for pediatric lacerations: a randomized trial of lidocaine-epinephrine-tetracaine solution versus gel. Annals of Emergency Medicine 1998;32(6):693-7. [MEDLINE: 9832666]
Schaffer 1985 {published data only}
Schilling 1995 {published data only}
  • Schilling CG, Bank DE, Borchert BA, Klatzko MD, Uden DL. Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Annals of Emergency Medicine 1995;25(2):203-8. [MEDLINE: 7832348]
Smith 1996 {published data only}
  • Smith GA, Strausbaugh SD, Harbeck-Weber C, Shields BJ, Powers JD, Hackenberg D. Comparison of topical anesthetics without cocaine to tetracaine-adrenaline-cocaine and lidocaine infiltration during repair of lacerations: bupivacaine-norepinephrine is an effective new topical anesthetic agent. Pediatrics 1996;97(3):301-7. [MEDLINE: 8604261]
Smith 1997a {published data only}
Smith 1997b {published data only}
  • Smith GA, Strausbaugh SD, Harbeck-Weber C, Cohen DM, Shields BJ, Powers JD. New non-cocaine-containing topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations. Pediatrics 1997;100(5):825-30. [MEDLINE: 9346982]
Smith 1998a {published data only}
  • Smith GA, Strausbaugh SD, Harbeck-Weber C, Cohen DM, Shields BJ, Powers JD, Barrett T. Prilocaine-phenylephrine and bupivacaine-phenylephrine topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations. American Journal of Emergency 1998;16(2):121-4. [MEDLINE: 9517683]
Vinci 1996 {published data only}
White 1986 {published data only}
  • White WB, Iserson KV, Criss E. Topical anesthesia for laceration repair: tetracaine versus TAC (tetracaine, adrenaline, and cocaine. Journal of Emergency Medicine 1986;4(4):319-22. [MEDLINE: 3718621]
Zempsky 1997 {published data only}

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Adler 1998 {published data only}
Adriansson 2004 {published data only}
  • Adriansson C, Suserud BO, Bergbom I. The use of topical anaesthesia at children's minor lacerations: an experimental study. Accident and Emergency Nursing 2004;12(2):74-84. [MEDLINE: 15041008]
Bartfield 1995 {published data only}
Bartfield 1996 {published data only}
Bass 1990 {published data only}
Bonadio 1988a {published data only}
Bonadio 1988b {published data only}
Bonadio 1992 {published data only}
Bonadio 1996 {published data only}
Chale 2006 {published data only}
Chipont 2001 {published data only}
  • Chipont Benabent E, Garcia-Hermosa P, Alio Y Sanz JL. Benabent Sutura de laceraciones cutaneas con gel LAT (lidocaina, adrenalina, tetracaina). Archivos de la Sociedad Espanola de Oftalmologia 2001;76:505-8.
Liebelt 1997 {published data only}
  • Liebelt EL. Current concepts in laceration repair. Current Opinion Pediatrics 1997;9(5):459-64. [MEDLINE: 9360822]
Little 2004 {published data only}
  • Little S, Brosnahan J. Topical anaesthetic applied at triage reduced treatment time in children presenting to the emergency department with minor lacerations. Evidence-Based Nursing 2004;7(1):9. [MEDLINE: N/A]
Peirluisi 1989 {published data only}
  • Pierluisi GJ, Terndrup TE. Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations. Pediatric Emergency Care 1989;5(4):211-5. [MEDLINE: 2602190]
Priestley 2003 {published data only}
  • Priestley S, Kelly AM, Chow L, Powell C, Williams A. Application of topical local anesthetic at triage reduces treatment time for children with lacerations: a randomized controlled trial. Annals of Emergency Medicine 2003;42(1):34-40. [MEDLINE: 12827121]
Singer 2000 {published data only}
Singer 2001 {published data only}
Smith 1990 {published data only}
  • Smith SM, Barry RC. A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children. Pediatric Emergency Care 1990;6(4):166-70. [MEDLINE: 2290723]
Smith 1998b {published data only}
  • Smith G, Strausbaugh S, Harbeck-Weber C, Cohen D, Shields B, Powers J. Prilocaine-phenylephrine topical anesthesia for repair of mucous membrane lacerations. Pediatric Emergency Care 1998;14(5):324-8. [MEDLINE: 9814396]
Smith 1998c {published data only}
  • Smith G, Strausbaugh S, Harbeck-Weber C, Cohen D, Shields B, Powers J. Tetracaine-lidocaine-phenylephrine topical anethesia compared with lidocaine infiltration during repair of mucous membrane lacerations in children. Clinical Pediatrics (Philadelphia). 1998;37(7):405-12. [MEDLINE: 9675433]
Spivey 1987 {published data only}
Stewart 1998 {published data only}
White 2004 {published data only}
Yamamoto 1997 {published data only}
  • Yamamoto LG, Young LL, Roberts JL. Informed consent and parental choice of anesthesia and sedation for the repair of small lacerations in children. American Journal of Emergency Medicine 1997;15(3):285-9. [MEDLINE: 9148989]

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Altman 1985
Berde 1991
  • Berde CB, Lehn BM, Yee JD, Sethna NF, Russo D. Patient-controlled analgesia in children and adolescents: a randomized, prospective comparison with intramuscular administration of morphine for postoperative analgesia. Journal of Pediatrics 1991;118(3):460-6. [MEDLINE: 1999793]
Bush 2002
Choiniere 1990
Crellin 2007
Dailey 1988
Daya 1988
Drug Facts 2003
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Grant 1992
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Highly sensitive search strategies for identifying reports of randomized controlled trials in MEDLINE; Chapter 6.3.2.1. Available from www.cochrane-handbook.org. Chichester, UK.
Kundu 2002
Lander 1993
RevMan 5.1
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Singer 1999
  • Singer A, Richman P, Kowalska A, Thode H. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Annals of Emergency Medicine 1999;33(6):652-8. [MEDLINE: 10339680]
Stephenson 1994
  • Stephenson NL. A comparison of nurse and patient: perceptions of postsurgical pain. Journal Intravenous Nursing 1994;17(5):235-9. [MEDLINE: 7965368]
Stoelting 1999
  • Stoelting R. Pharmacology And Physiology In Anesthetic Practice. Pharmacology and physiology in anesthetic practice. Lippincott Williams and Wilkins, 1999.
Terndrup 1992
  • Terndrup TE, Walls HC, Mariani PJ, Gavula DP, Madden CM, Cantor RM. Plasma cocaine and tetracaine levels following application of topical anesthesia in children. Annals of Emergency Medicine 1992;21(2):162-6. [: 1739203]
Tipton 1988
Tyler 1993
Vinci 1999
Wehner 1984
Zeltzer 1991