A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children

A randomized, prospective, double-blind study comparing three formulations of the topical anesthetic solution TAC for laceration repair was undertaken in 250 children. The children's wounds were anesthetized with either TAC I (original formulation--0.5% tetracaine, 1:2000 Adrenalin, 11.8% cocaine), TAC II (1.0% tetracaine, 1:4000 Adrenalin, 7.0% cocaine), or TAC III (1.0% tetracaine, 1:4000 Adrenalin, 4.0% cocaine) prior to repair. The solutions were compared with respect to efficacy, acceptability, wound complications, and side effects. We found comparable efficacy of the three formulations, with similar efficacy to 1% lidocaine infiltration for facial and scalp wounds. Anesthesia for extremity wounds was adequate in only 39.9% of cases, regardless of TAC strength. Wound complications and side effects were within expected and acceptable limits. Our findings support use of TAC for face and scalp lacerations and a change to a less concentrated TAC preparation, such as our "TAC III," which is presumably safer for widespread use.     

New non-cocaine-containing topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations

OBJECTIVE: To compare the effectiveness of three new topical anesthetics that do not contain cocaine (prilocaine-phenylephrine, tetracaine-phenylephrine [tetraphen], and tetracaine-lidocaine-phenylephrine) to that of tetracaine-adrenaline-cocaine (TAC) during laceration repair in children. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: The emergency department of an urban children's hospital. PARTICIPANTS: Children 1 year of age or older with a laceration /= 5 years of age using a visual analogue scale (VAS). Suture technicians, research assistants, and parents also scored pain using a seven-point Likert scale. In addition, suture technicians completed an anesthetic effectiveness scale. RESULTS: There was consistently no difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. A statistically significant difference was seen among anesthetics when comparing VAS and Likert scale scores of suture technicians and Likert scale scores of research assistants. Based on post hoc analyses, these statistically significant differences were between TAC and prilocaine-phenylephrine (suture technician VAS and Likert scale) and between TAC and tetracaine-lidocaine-phenyl-ephrine (suture technician Likert scale), but not between TAC and tetraphen. When power analyses were performed using alpha = 0.05 and beta = 0.20, it was possible to detect a difference of 1.2 VAS units for each of the observer groups. Based on anesthetic effectiveness scale scores, the three new topical preparations collectively performed significantly better on the face and scalp than on the extremities (relative risk = 1.83; 95% confidence interval 1.20 < relative risk < 2.79). CONCLUSION: This study demonstrated the effectiveness and safety of three new non-cocaine-containing topical anesthetics. Consistently, there was no statistical difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. Tetraphen offers an effective alternative to TAC during laceration repair in children.     

Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations

Local anesthetic infiltration of wounds causes pain which distresses children. A painless topical anesthetic solution containing tetracaine, adrenaline, and cocaine (TAC) may reduce this distress. We hypothesized that the use of TAC for anesthesia may reduce the utilization of sedation for laceration repair. We performed a retrospective review of all pediatric emergency department (PED) patients receiving parenteral meperidine, promethazine, and chlorpromazine (DPT) during the period after TAC became routinely available. For comparison, data from a recent retrospective study of DPT (preTAC) use in the same PED were used. There was a reduction in the percent of total PED patients receiving DPT, from 1.7% preTAC to 1.2% during the TAC period (P less than 0.05). During the TAC period, there were no significant changes in patient volume or case-mix indicators. Of the major indications for DPT, there was no significant change in the percent receiving DPT for fractures, abscesses, burns, foreign body removal, or head injuries. However, there was a significant reduction in the percent of patients with lacerations receiving DPT during the experimental period, from 12% to 7.6% (P less than 0.05). There were no significant differences in laceration frequency (119/mo and 116/mo), length (2.7 and 2.7 cm), location (85% and 93% total for face and digits), or complexity (64% and 63%) for preTAC and TAC periods, respectively. We conclude that TAC used for local anesthesia may reduce the need for sedation in PED patients with lacerations that require suturing.     

New concepts in wound management

Children with lacerations and other minor wounds are among the most often encountered in the ED. The steps in management of these patients are well-known and often well-researched, but dogma still permeates the process. Local anesthetics are effective, and several choices are available. New topical creams and expanded indications for the currently available anesthetics will enhance patient comfort during laceration cleaning and repair. Irrigation with tap water is a safe, effective and economic method of cleaning wounds, and perhaps even the use of sterile gloves is superfluous in preventing wound contamination. Several alternative wound-closure materials are currently available including tissue adhesive in an array of applicators and formulations, adhesive strips, staples, and nonabsorbable as well as absorbable suture material. Finally, prophylaxis for tetanus is a simple, if possibly underused, technique. Further research into new materials and procedures will only improve our care of patients who have sustained skin trauma.     

Blunt laryngeal trauma in children: case report and review of initial airway management

Blunt neck trauma is not common in children, but these injuries can be potentially life-threatening. Presenting symptoms and signs of laryngeal injuries are often subtle, and poor outcomes in regard to voice and airway function are associated with delayed diagnosis. The purpose of this report was to present a pediatric case that illustrates the subtle symptoms and signs of a laryngeal laceration. In this case, the appearance of the laryngeal laceration was similar to the glottis, highlighting the importance of developing airway management guidelines for blunt laryngeal injuries in children.     

Barbiturates

Sedation remains the most important, and sometimes the most difficult part of diagnostic or therapeutic procedures in children. Today, computed tomography (CT) scan and magnetic resonance imaging, (MRI) are widely used in the evaluation of pediatric disease; and the need for safe and effective sedation practice has grown. Pentobarbital, thiopental, and methohexital are 3 barbiturates that have gained popularity in the pediatric emergency department for sedation Pentobarbital II has been used With great success when sedation is required for unnllainful procedures in the emergency department setting Thiopental was used in the early 1980s but lost popularity in the 1990s. Methohexital because of its ultrashort-acting properties, has gained popularity for use in painful (eg, fracture reduction, laceration repair) and nonpainful procedures (eg, CT scanning, MRI). In this article, each drug is discussed for routes of administration, side effects. contraindications, and overall success rates.     

Half-strength TAC topical anesthetic. For selected dermal lacerations

A prospective evaluation of 75 consecutive children with lacerations of the face, lip, and scalp who received TAC (tetracaine, epinephrine [adrenalin], cocaine) topical anesthetic for the repair of their wound was performed. The TAC preparation contained one-half the conventional concentration of cocaine (5.9%) and tetracaine (0.25%) previously used in other studies that have evaluated its anesthetic efficacy. A maximal dosage of 3 ml of TAC (containing 175 mg cocaine and 7.5 mg tetracaine) was applied to each laceration. The diluted TAC preparation provided complete anesthesia for approximately 95% of the more than 400 sutures placed. No adverse reactions were noted in any patient who received TAC, and in no instance did a complication of wound healing occur. The original formulation of TAC was arbitrarily composed, and the maximum concentration per dosage of the potentially toxic component medications of TAC that can be "safely" applied to dermal lacerations in children remains to be defined. Utilization of this diluted preparation will diminish the risk of potential systemic toxicity from the absorbed component medications of TAC without compromising anesthetic efficacy.     

Intranasal Ketamine for Procedural Sedation in Pediatric Laceration Repair: A Preliminary Report

OBJECTIVE: The objective of this study was to compare the efficacy of 3 doses of intranasal ketamine (INK) for sedation of children from 1 to 7 years old requiring laceration repair. METHODS: This was a randomized, prospective, double-blind trial of children requiring sedation for laceration repair. Patients with simple lacerations were randomized by age to receive 3, 6, or 9 mg/kg INK. Adequacy and efficacy of sedation were measured with the Ramsay sedation score and the Observational Scale of Behavioral Distress-Revised. Serum ketamine and norketamine levels were drawn during the procedure. Sedation duration and adverse events were recorded. RESULTS: Of the 12 patients enrolled, 3 patients achieved adequate sedation, all at the 9-mg/kg dose. The study was suspended at that time as per predetermined criteria. CONCLUSIONS: Nine milligrams of INK per kilogram produced a significantly higher proportion of successful sedations than the 3- and 6-mg/kg doses.     

脑红蛋白在小儿脑挫裂伤病理过程中变化的初步研究

目的：初步探讨脑红蛋白（neuroglobin, Ngb）在小儿脑挫裂伤病理生理过程中的作用。方法：采用二维凝胶电泳技术分离3例行脑室肿瘤切除患儿的正常额叶皮层组织和8例脑挫裂伤患儿额叶皮层组织总蛋白质,PDquest图像分析软件识别差异蛋白质点,电喷雾串联质谱鉴定差异蛋白;免疫组化检测差异蛋白Ngb在正常脑组织和脑挫裂伤患儿的脑组织中的表达。并采用酶联免疫法检测10例正常儿童和15例脑挫裂伤患儿血清中Ngb的表达变化。结果：建立了正常儿童和脑挫裂伤患儿脑组织的二维凝胶电泳图谱,识别了6个差异蛋白质点,并鉴定了5种差异蛋白。免疫组化结果显示,Ngb在脑挫裂伤患儿额叶皮层组织中的表达水平高于正常对照组额叶皮层组织（P<0.05）。酶联免疫法检测结果表明,脑挫裂伤后6 h、12 h、18 h、24 h及48 h 血清Ngb表达高于正常对照组,差异有统计学意义（P<0.01）。结论：Ngb可能在小儿脑挫裂伤病理生理过程中发挥了重要作用。     

Comparison of two benzodiazepines used for sedation of children undergoing suturing of a laceration in an emergency department

OBJECTIVES: (1) To determine if oral diazepam (POD) is as effective in sedating children less than 6 years of age for laceration repair as oral midazolam (POM) or intranasal midazolam (INM); and (2) To determine if patients stayed longer in the department after sedation when given POD for sedation. DESIGN/METHODS: Block-randomized, single-blind trial. SETTING: Tertiary pediatric emergency department. PARTICIPANTS: Patients 1 to 5 years old with a laceration requiring sutures were enrolled. INTERVENTIONS: All patients had topical anesthetic applied to the wound and were randomly assigned to POD 0.5 mg/kg, POM 1.0 mg/kg, or INM 0.4 mg/kg for sedation. RESULTS: One hundred twenty-nine patients were enrolled, 42 POD, 45 POM, and 42 INM. Each group was similar at baseline for age, heart rate, respiratory rate, blood pressure, oxygen saturation, previous laceration or sedation, anxiety score, and site of laceration. POM and POD were better tolerated than INM (P = 0.05 and 0.034), respectively. Time to sedation was significantly longer in POD (31.0 +/- 9 min) than INM (26.1 +/- 9 min) (P = 0.011) but there was no significant difference when comparing the other groups. However, this difference was not clinically significant. POD was significantly worse at sedating children compared with POM and INM on all four scores (ie, doctor, nurse, parent, and investigator), but INM and POM were equivalent. Total time in the department was no different between POM and INM or POM and POD, but was significantly different for POD (53.9 +/- 16 min) and INM (48 +/- 12 min); however, this difference was minimal. More patients were said to be drowsy at home in the POM group (51%) than the POD group (32%). CONCLUSIONS: The oral route of delivery of POM and POD was better tolerated than INM. POM and INM were more effective at sedation than POD, but there was no clinical difference between any groups for time to sedation or time to discharge. More patients in the POM group had side effects after leaving the department. POD may be an alternative to POM, but a higher dose may be required, possibly with longer recovery times.     

Ketamine

Ketamine has been extensively studied and has become increasingly popular over the past several years for emergency department sedation in children.Common procedures for which ketamine can be used include burn debridement, foreign body removal, fracture reduction, incision and drainage of an abscess, and laceration repair. Ketamine provides reliable and consistent sedation, analgesia, and amnesia, coupled with an excellent safety profile. Ketamine's rapid onset, combined with a relatively short duration, make it ideal for children requiring sedation for brief procedures. Significant side effects, such as laryngospasm and emergence reactions, are uncommon. Overall, compared with many of the available alternatives, ketamine is frequently an excellent choice for children in the emergency department who require sedation for painful procedures.     

Metal lawn and garden edging: the hidden knife?

OBJECTIVE: Lacerations account for many visits to the pediatric emergency department. We observed children presenting to local emergency departments in a large metropolitan area with lacerations incurred from metal lawn and garden edging, a landscaping tool. We sought to describe the severity of lacerations caused by metal edging, the characteristics of wound repair, and the need for subspecialty consultation. DESIGN: A retrospective chart review including all pediatric patients (< 18 years) presenting with lacerations caused by metal lawn and garden edging from January 1995 to October 1997 was performed. Patients were seen at one of three emergency departments in Colorado. RESULTS: One hundred twenty-six patients were enrolled (76% male, 24% female), with a median age of 9 years. The most frequent location of laceration was the foot (40%), followed by the knee (26%). The median length of laceration was 3 cm (range 1-22 cm). Sixteen patients (13%) received either intravenous or oral antibiotics, and six patients (5%) received orthopedic evaluation. CONCLUSIONS: Metal lawn and garden edging in landscaped neighborhoods presents a previously undescribed laceration danger to children. Some lacerations sustained from the metal lawn edging are extensive, receiving either multiple layer closure and/or the need for subspecialty consultation.     

Topical anesthetics in children: agents and techniques that equally comfort patients, parents, and clinicians.

Topical anesthetics are increasingly important, as the number of outpatient surgeries for dermatologic problems in infants and children is steadily growing. This noninvasive modality of anesthetic delivery in conjunction with a reassuring environment may minimize the discomfort of otherwise painful procedures. Since the 1880s, when cocaine was first used as a topical ophthalmologic anesthetic, many ester-and amide-based local anesthetics have been developed for a variety of simple and complex procedures. The pediatric dermatologist's arsenal of topical anesthetic preparations is increasing with the development of novel vehicles of transdermal delivery and the use of anesthetics in combination. Eutectic mixture of local anesthetics is currently the most frequently prescribed topical agent, though the use of ELA-max, another lidocaine-containing preparation, is gaining momentum, especially in the neonatal population. Amethocaine, tetracaine, iontophoresis, and the S-caine patch, a product on the horizon for use in the pediatric population, also are included in this discussion.     

Pediatric chin injury: occult condylar fractures of the mandible

The diagnosis of occult mandibular condylar fractures in children is often missed or delayed on initial examination when children present with a laceration to the chin. A clue to the diagnosis of this type of skeletal injury to the mandible is the knowledge of a commonly occurring pattern of injury associated with chin trauma. Chin laceration, fracture of the parasymphyseal region near the chin, and fracture of the condyles are often concomitant injuries of the mandible. This article reviews three case reports of children who sustained a chin laceration, fracture in the region near the chin, and fracture to the mandibular condyles secondary to chin trauma that were not initially diagnosed on clinical examination.     

What's new in pediatric dermatology: update for the pediatrician

PURPOSE OF REVIEW: Common pediatric skin conditions such as infantile atopic dermatitis, vitiligo, hemangiomas of infancy, warts, and molluscum contagiosum do not always respond to standard therapy. In some settings pediatricians will use "off-label" medications if the benefit-to-risk ratio is favorable. This article reviews important literature from the past year related to "off-label" immune-based treatment of skin disease, using the topical immunomodulators tacrolimus, pimecrolimus, and imiquimod, as well as intravenous Ig. RECENT FINDINGS: The topical immunomodulators tacrolimus and pimecrolimus have been embraced by pediatricians as long awaited alternatives for treating atopic dermatitis in children 2 years of age and older. Their unique appeal as nonsteroidal topical agents with good safety profiles has led to their frequent use for unapproved indications. A number of recent publications detail their use in infantile atopic dermatitis in children as young as 3 months of age, as well as use in other conditions such as vitiligo. Imiquimod, another topical immunomodulator, approved for genital wart treatment in adults, has also been examined for "off-label" pediatric use in nongenital warts, molluscum contagiosum, hemangiomas of infancy, and basal cell carcinoma. Finally, "off-label" use of intravenous Ig has been evaluated for the life-threatening dermatoses Stevens-Johnson syndrome and toxic epidermal necrolysis. SUMMARY: In the absence of larger controlled trials, pediatricians must consider the cumulative weight of smaller studies with their personal experience when assessing any role for "off label" therapy. The recent literature reviewed herein will facilitate such assessments of the non-steroid topical immune modifiers tacrolimus, pimecrolimus, and imiquimod as well as intravenous immunoglobulin.     

The Nutrition Commission of the Austrian Society of Pediatrics and Adolescent Medicine. Prevention of caries]

Effective preventive programs must be instituted early in the life of a child. The pediatrician plays an important role in preventive oral health care, because most children do not visit a dentist before 3 years of age. Fluoride therapy decreases the caries vulnerability of the tooth, oral hygiene measures are important to remove bacterial plaque, and dietary modifications reduce the number of carbohydrate exposures per day. Community water fluoridation is proposed in Austrian cities, because it continues to be the most cost-effective caries prevention measure available. As long as the population does not have access to optimally fluoridated water, dietary fluoride supplementation offers an effective alternative. The recommended dosage of fluoride supplements for children depends on the amount of fluoride present in their drinking water and on the child's age. Liquid fluoride supplements and chewable tablets are proposed for children between 0.5 and 3 years and children between 3 and 13 years, respectively. Home use topical fluorides and professionally applied topical fluorides are useful beyond 3 years of age. Teaching of oral hygiene measures should be continued in kindergarten and school. The 3-6 year-old children require parental assistance to achieve effective plaque removal. Semiannual dental visits should begin at the age of three and continue throughout childhood and adolescence. As far as the diet is concerned, the frequency of exposure to sugar appears to be the most important factor in the development of dental caries. It now appears that most sugars are nearly equally cariogenic in a pure form.     

Baby walker injuries

BACKGROUND: Baby walkers (BWs) are still commonly used. The resultant injuries are largely preventable. Understanding the reasons for their use and the circumstances leading to these accidents might lead to prevention. OBJECTIVES: To study the reasons for using BWs, how accidents occur, types of injury and their management. METHODS: Mothers of 100 children were interviewed while admitted or in the emergency room. The questionnaire included reasons for BW use, predisposing circumstances and types of injury sustained. RESULTS: BWs were used by 83% of the children (44% girls, 39% boys), starting at an age between 5 and 8 months. Reasons for use were: to be occupied, 71%; to walk earlier, 54%; to strengthen the legs, 28%. Accidents were sustained by 78 (94%) of the infants as a result of BW use. The reasons were: being pushed by someone, 37%; BW mechanical defect, 36%; tripping, 22%. The commonest place was in a corridor (52%). Head injuries were sustained by 82% and included bruising, epistaxis, cut lip, tooth damage, cut tongue, skin abrasions and skull fracture. Limb injuries were sustained in 17%: laceration and/or abrasion, bruising and joint dislocation. CONCLUSIONS: Injury from use of BWs is still common. Doctors should discourage their use and parents informed about the attendant hazards. A playpen is a safer place for young children.     

Iatrogenic injury in childhood staphylococcal scalded skin syndrome

Staphylococcal scalded skin syndrome (SSSS) may cause significant morbidity in children. It is common practice for adhesive occlusive dressings to be used to apply topical local anaesthetic prior to venepuncture. We report two cases in which removal of these dressings from children with SSSS caused injury and discomfort in areas previously free from blistering. We recommend that an alternative method of topical anaesthetic application is used to minimize skin trauma in these patients.     

Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children

To determine whether the tetracaine component traditionally used in tetracaine-adrenaline-cocaine (TAC) is necessary to obtain effective topical anesthesia, a prospective study was performed to compare TAC and adrenaline-cocaine preparations for the repair of facial lacerations in children. Physicians were "blind" to which preparation was being used. Of 55 patients studied, 24 received TAC (103 sutures placed) and 31 received adrenaline-cocaine (151 sutures placed). The anesthetic efficacy of each preparation was approximately 95%; there were no adverse reactions related to administration of either medication or complications of wound healing noted in either group. The tetracaine component of TAC is superfluous for obtaining topical anesthesia of minor dermal lacerations of the face in children. The TAC formulation can be simplified by omitting tetracaine without compromising anesthetic efficacy.     

Does EMLA cream application interfere with the success of venipuncture or venous cannulation? A prospective multicenter observational study

Venipuncture and intravenous cannulation are the most common painful procedures performed on children. The most widely used topical anesthetic is eutectic mixture of local anesthetics (EMLA). EMLA use is associated with a transient cutaneous vasoconstriction which can make it difficult to identify veins. We assessed with a prospective, multicenter, observational study whether EMLA interferes with venipuncture and intravenous cannulation. The primary study outcome was a success at first attempt in the course of venipuncture or venous cannulation. The study enrolled 388 children; 255 of them received EMLA and 133 did not. Eighty-six percent of procedures were successful at the first attempt in the EMLA group and 76.7 % in the no EMLA group. Conclusion: In this study, EMLA use did not interfere with the success of venipuncture or venous cannulation in children.