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PED-EM-L  March 2009

PED-EM-L March 2009

Subject:

Re: LET

From:

Amy Baxter <[log in to unmask]>

Reply-To:

Amy Baxter <[log in to unmask]>

Date:

Fri, 13 Mar 2009 12:29:23 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (249 lines)

Hello, Fernando  -

You'll love switching to LET, it's amazing.  Here's a little bit from a
piece I wrote on LET....I apologize for cutting and pasting.  There are a
few abstracts pasted in thereafter, and references at the bottom.  Feel
free to contact me off list with any other questions.  Take care, hope
this helps
Amy


LOCAL ANESTHESIA FOR OPEN WOUNDS
Open lacerations permit easy absorption, rendering the hydrophilic ester
issue moot. The first combinations included tetracaine and cocaine mixed
with a vasoconstrictor (“adrenaline”) to decrease diffusion.  This
mix, “TAC”, was very effective with minimal toxicitiy when placed
directly into the wound.  TAC essentially obviated the need for injection
for many pediatric cuts.  The use of the controlled substance cocaine,
however, both increased the cost and logistical difficulty of keeping the
mix available.  In 1995, Ernst et al demonstrated that lidocaine,
epinephrine and tetracaine (LET or LAT) were just as effective.(1)  This
has become standard of care for pediatric wound repair, either with a
single application or with sequential applications.(2)
A shred of LET-soaked cotton or LET mixed with methylcellulose is placed
directly in the wound prior to cleansing and repair.  The solution or gel
can be held in place with an occlusive dressing, tape, or bandage, but
care must be taken not to put any absorptive surface near the LET, as this
will wick the medication away from the wound.  The wound edges blanch when
numb, usually after 20 minutes.  Anesthesia lasts an average of 21 minutes
after removal.(3) LET alone gives sufficient pain control in 60% of
adults,(4) 70 – 90% of pediatric facial lacerations,(3) and 40 – 75%
of extremity wounds.(5)  In addition, use in children decreased length of
stay (LOS) from 108 to 77 minutes.(6)
One study exclusively in pediatric finger lacerations found an efficacy of
approximately 50%.  They found no cases of digital ischemia, nor did
another that left LET on for 15 minutes.(5, 7)   The combined N were 67
and 23, respectively, so these small numbers are reassuring but do not
establish safety.  While absorption of lidocaine through mucous membranes
is a theoretical concern, the use of LET for oral lacerations is more
limited by loss of the pigmentation of the vermillion border from
blanching.
The recipe is somewhat complicated: lidocaine 20%100ml (20g lidocaine
powder, 100ml NS); racemic epinephrine 2.25% 50ml; tetracaine 2% 125ml;
sodium metabisulfate 315.4mg; 225ml sterile water, yielding a total of
500ml of LET.  This will keep three weeks at room temperature, or five
months refrigerated.
~

TI  - Expanding the use of topical anesthesia in wound management:
sequential
      layered application of topical lidocaine with epinephrine.
PG  - 379-84
AB  - Topical anesthesia eliminates the need for injection of anesthetic.
Most
      studies on the use of topical anesthesia were done on children,
using 3
      active ingredients (lidocaine, epinephrine, tetracaine, or
tetracaine,
      adrenaline, cocaine) for relatively small wounds of the face and
scalp.
      OBJECTIVES: To demonstrate that topical anesthesia is effective and
safe
      in adults of all ages and for larger wounds, using a preparation
with 2
      active ingredients, topical lidocaine and epinephrine (TLE).
METHODS: One
      hundred patients were enrolled in a randomized controlled trial,
with 50
      in each group. The study group received TLE using a unique method of
      "sequential layered application." The control group received 2%
lidocaine
      infiltration anesthesia. Patients rated the pain from the
application of
      anesthesia and from suturing, using a 0 to 10 visual analog pain
scale.
      Follow-up interviews were conducted to assess for complications and
to
      rate patients' wound repair experience. RESULTS: Patients in the
study
      group reported significantly less pain from TLE application, with 66%
      reporting no pain vs 0% reporting no pain from the infiltration in
the
      control group (P < .001). There was no difference in pain during
wound
      repair between the 2 groups (P approximately .59). On follow-up, 95%
of
      patients contacted in the TLE group rated their experience in regard
to
      pain as "excellent," compared to 5% of patients in the control group
(P <
      .001). CONCLUSION: Topical lidocaine and epinephrine "sequential
layered
      application" is an effective, safe, and less painful method of
anesthesia
      for a wide variety of lacerations. Patients recall their experience
with
      this technique very favorably.
AD  - Department of Emergency Medicine, The Cambridge Hospital, Cambridge
Health
      Alliance, Division of Emergency Medicine, Harvard Medical School,
Boston,
      MA 02139, USA. [log in to unmask]
FAU - Gaufberg, Slava V
AU  - Gaufberg SV
PMID- 7838644
OWN - NLM
STAT- MEDLINE
DA  - 19950227
DCOM- 19950227
LR  - 20061115
PUBM- Print
IS  - 0031-4005 (Print)
VI  - 95
IP  - 2
DP  - 1995 Feb
TI  - 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.
PG  - 255-8
AB  - STUDY OBJECTIVE. The purpose of the present study is to compare LAT
gel
      (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) to TAC gel (0.5%
      tetracaine, 1:2000 adrenaline, 11.8% cocaine) for efficacy, side
effects,
      and costs in children aged 5 to 17 years with facial or scalp
lacerations.
      DESIGN. Randomized, prospective, double-blinded clinical trial.
SETTING.
      Inner-city Emergency Department with an Emergency Medicine residency
      program. PATIENTS OR OTHER PARTICIPANTS. Children aged 5 to 17 years
with
      linear lacerations of the face or scalp. INTERVENTION. After informed
      consent was obtained patients had lacerations anesthetized with
topical
      TAC or LAT gel according to a random numbers table. MEASUREMENTS AND
MAIN
      RESULTS. A total of 95 patients were included in the statistical
analysis
      with 47 receiving TAC and 48 receiving LAT. Physicians and
      patients/parents separately rated the overall pain of suturing using
a
      modified multidimensional scale for pain assessment specifically for
      children. Patients/parents also stated the number of sutures causing
pain.
      The power of the study to determine a ranked sum difference of 15
was 0.8.
TI  - Topical anesthesia for pediatric lacerations: a randomized trial of
      lidocaine-epinephrine-tetracaine solution versus gel.
PG  - 693-7
AB  - STUDY OBJECTIVE: To compare the adequacy and efficacy of anesthesia
      experienced with lidocaine-epinephrine-tetracaine (LET) solution
versus
      LET gel during suturing of uncomplicated lacerations on the face or
scalp
      in children. METHODS: Two hundred children with lacerations of the
face
      and scalp requiring suturing were enrolled in this blinded,
randomized
      controlled trial, in the emergency department of a
university-affiliated
      children's hospital. After the application of anesthetic solution or
gel,
      adequacy of anesthesia was determined before suturing. Efficacy of
      anesthesia during laceration repair was determined by the length of
time
      after removal of the topical anesthetic to the first sign of
discomfort
      that required additional anesthesia or until suture completion.
RESULTS:
      Adequacy of initial anesthesia was equivalent between LET solution
and LET
      gel. There was a significant difference in efficacy of anesthesia
between
      the LET formulations. There were more patients with complete
anesthesia
      (85% versus 76%), fewer persons with partial anesthesia (5% versus
21%),
      and more persons with incomplete anesthesia (9% versus 3%) in the gel
      group. CONCLUSION: LET gel is at least as effective as LET solution
and
      possesses theoretical advantages for topical anesthesia during
suturing of
      uncomplicated lacerations on the face and scalp in children.
AD  - Emergency and Clinical Pharmacy Departments, Children's Hospitals and
      Clinics-Minneapolis, MN, USA.

1.	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):255-8.2.	Gaufberg SV, Walta MJ,
Workman TP. Expanding the use of topical anesthesia in wound management:
sequential layered application of topical lidocaine with epinephrine. Am J
Emerg Med 2007;25(4):379-84.3.	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. Ann Emerg
Med 1998;32(6):693-7.4.	Adler AJ, Dubinisky I, Eisen J. Does the use of
topical lidocaine, epinephrine, and tetracaine solution provide sufficient
anesthesia for laceration repair? Acad Emerg Med 1998;5(2):108-12.5.	Atiba
JO, Horai Y, White PF, Trevor AJ, Blaschke TF, Sung ML. Effect of
etomidate on hepatic drug metabolism in humans. Anesthesiology
1988;68(6):920-4.6.	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. Ann Emerg
Med 2003;42(1):34-40.7.	Chale S, Singer AJ, Marchini S, McBride MJ,
Kennedy D. Digital versus local anesthesia for finger lacerations: a
randomized controlled trial. Acad Emerg Med 2006;13(10):1046-50.

This was their recipe:
Lidocaine powder 2.4 grams~Epi 1:1000 30 ccTetracaine 2% 50 ccNS 15
ccGelfoam 1 gram (12 ml prepared)
They referenced univ. Of Kansas med. Center pharmacy, February annals of
emer. Med 1995

 Fernando Soto <[log in to unmask]> writes:
>Hello all. I am working at a Residency Program in PR where I am the only
>Peds EM trained physician and one of my initial projects has been to
>improve the treatment of pain in our pediatric population. Does anybody
>have any experience with this in their hospital? I specifically need
>whatever information you have regarding how to prepare LET, what does the
>pharmacy need to do to prepare and provide the medication, and how to
>train my nurses to identify potential patients and administer the
>medication. I appreciate all your help.
>
>Thank you, 
>
>Fernando Soto, MD
>
>Pediatric Emergency Section
>
>Emergency Medicine Program
>
>University of Puerto Rico
>
>School of Medicine
>



Amy Baxter MD FAAP FACEP
Director of Emergency Research, Scottish Rite
Pediatric Emergency Medicine Associates
Clinical Assoicate Professor, Scottish Rite
404 371-1190


For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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