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Wound Anesthesia: Local Infiltration and Topical Agents Assisting

  1. Assess for pain, pulses, pallor, paralysis, paresthesias, and pressure.
  2. Carefully question the patient about medication allergies. Allergic reaction is more common with ester preparations such as cocaine, benzocaine, tetracaine, and procaine.
  3. Collaborate with the physician or advanced practice nurse to determine the appropriate route and type of anesthetic agent.
  4. Perform hand hygiene and apply gloves.
  5. Verify the patient's identity in accordance with institution policy.
  6. Call or participate in a "time out" before initiating an invasive procedure, in accordance with institutional polic
Topical Agents—Options
  1. EMLA: Apply a thick layer (1 to 2 grams [g]/10 cm2) of EMLA to intact skin under an occlusive dressing for approximately 30 minutes to 1 hour before a procedure. For minor procedures such as needle insertions, apply 2.5 g of EMLA over 20 to 25 cm2 for at least 1 hour. Preparation of two potential sites is recommended when an intravenous line is started, in the event of technical difficulties at the initial site. When a more painful procedure is anticipated, apply 2 g of EMLA per 10 cm2 for at least 2 hours.
  2. Other topical patches or creams as prescribed (such as Synera, etc.): Use as directed noting absorption times and maximum doses or length of application.
  3. Lidocaine: Apply lidocaine topically as a liquid, ointment, jelly, or viscous fluid (2%- 10%). Absorption is rapid. Do not exceed recommended dosage (maximum safe dosage is 250 to 300 mg).
  4. Benzocaine and tetracaine: Use sprays containing benzocaine and tetracaine (e.g., Cetacaine, Hurricaine) primarily for oral procedures. Spray applications should not exceed 2 seconds.
  5. Anesthetic solutions: Use LET primarily for minor facial and scalp lacerations in lieu of injectable anesthetic, especially in children.
  6. Clean the wound to remove debris and clots before using LET to increase its efficacy.
  7. Apply LET by saturating sterile gauze and applying it to the wound with firm pressure for 15 to 20 minutes with gloved hands to prevent skin absorption for the caregiver. LET solution may also be applied by dripping into a wound with a syringe or by applying to a wound with sterile cotton swabs. LET gel is spread directly in the wound. The gel or solution-soaked gauze may be held in place with a clear bioocclusive dressing or elastic bandage.
  8. Take care to ensure that LET does not run or drip into the eyes, nasal passages, or mouth. Observe the patient carefully during and after administration.
  9. If the first dose of LET is not effective, infiltrate the laceration with local anesthesia; do not apply another dose of LET.
  10. Assess adequacy of anesthesia by testing sharp-dull sensation and observing blanching (if an epinephrine containing solution was used) before beginning the procedure.
Wound Infiltration
  1. Use one of several techniques during wound infiltration to decrease pain:
  2. Buffering lidocaine may reduce pain with injection. Lidocaine is buffered by adding 1 ml of sodium bicarbonate (8.4%) to every 10 ml of lidocaine solution. It remains effective after mixing for 1 week.
  3. Consider the anesthetic agent that most fits the patient's need. A longer-acting local anesthetic (bupivacaine) may prevent the wound from having to be reinfiltrated, especially in a busy emergency department. Lidocaine has a more rapid onset, but it has a short duration of action. Attempt to avoid reinfiltration, especially in children or in wounds in which tissue viability is already a problem, such as in the face. If prolonged postanesthesia pain is anticipated, bupivacaine is useful.
  4. Use the smallest possible needle for infiltration. A 27-gauge needle is usually adequate except for digital blocks, the scalp, or calloused areas; in these situations, a 25-gauge needle may be required.
  5. Slow administration of anesthetic intradermally through the inside margins of wound edges with small-gauge needles causes less pain.
  6. The physician or advanced practice nurse infiltrates the wound edges through the dermis and not through the skin. As the needle passes through the dermis, injection continues. Some clinicians recommend injection through surrounding intact skin if the wound is grossly contaminated.
  7. As additional needle entry is needed, the physician or advanced practice nurse reenters through areas already infiltrated with anesthetic to lessen the pain of infiltration.
  8. Assess sharp-dull sensation to ensure adequate anesthesia before beginning the procedure. If epinephrine has been used, observe the wound edges for blanching.
Post Procedure
  1. Reassess pain; distal pulses; skin color, temperature, and moisture; motor status; sensory status; and edema.
  2. Apply a dressing as indicated.
  3. Discard supplies, remove gloves, and perform hand hygiene.
  4. Document the procedure in the patient's record.