The anxiety, pain, and fear that children and their parents experience during a crisis situation is a challenge frequently encountered in hospital emergency rooms. The inclusion of topical anesthetics and tissue adhesives for the treatment of facial and scalp lacerations has been found to help make the experience a less traumatic one for both children and parents.
Studies on topical versus intradermal anesthetics have shown that topical anesthetics can provide painless, effective and safe application, and minimize both children's and healthcare workers' exposure to needles. Tetracaine, epinephrine, and cocaine (TAC) and lidocaine, epinephrine (adrenalin), tetracaine (LET or LAT) are two anesthetic solutions that can be used. Studies have shown there is no significant difference between TAC or LET in adequacy of anesthesia before suturing or in duration during suturing, age or sex of the patient, amount of solution used, wound size, location, or number of sutures.
The use of tetracaine and cocaine found in TAC provide excellent local anesthesia. The epinephrine and cocaine cause vasoconstriction, which in turn minimizes bleeding, decreases the amount of local anesthetics absorbed through the skin, and limits toxicity. TAC, however, is expensive to prepare (up to 17 times the cost of LET), and there are federal drug control issues concerning cocaine that must be followed. Other issues to consider are complications such as hyperexcitability, euphoria, tachycardia, hypertension, seizures, respiratory distress, corneal abrasions, and even death from absorption of cocaine. Solutions of TAC without cocaine (TA) and tetracaine alone have been unsuccessful in effectively anesthetizing wounds. Since cocaine is not in the LET mixture, however, it is safer, less costly, and avoids regulations for using a controlled substance.
Another study compared the use of a noninvasive tissue adhesive (Histoacryl blue) to nondissolvable sutures and dissolvable sutures. The results showed that the efficacy, complication rate, cosmetic outcome, rate of dehiscence, and infection were similar. Histoacryl blue, however, was a faster and less painful method of facial laceration repair. When compared with sutures, Histoacryl blue required less time for application by medical personnel, less additional supply costs, fewer follow-up appointments, and less parental lost wages. Although the adhesive itself is relatively expensive, a cost analysis found that nondissolvable sutures had the highest total cost and the tissue adhesive the lowest. Ninety percent of the parents who were given a survey describing the three types of laceration closure and costs preferred the tissue adhesive method.
Studies have shown that LET Histoacryl blue are safe, effective, and less expensive alternative methods of uncomplicated facial and scalp laceration repair. As health care professionals we not only have the responsibility to promote treatment methods which are safe and cost effective, but those that can ease the fear, anxiety, and pain that our pediatric patients experience.
DERMABOND Tissue Adhesive is manufactured by Closure Medical Corporation, Raleigh, NC, www.dermabond.com.
March 15, 2002
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