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If the procedure is likely to take longer than 1 to 1.5 hours, then 0.25
percent bupivacaine can be added to the 1 percent lidocaine to prolong
its effect. Generally, epinephrine is not used in the local anesthetic for
children.
Anesthetic solutions may be buffered with sodium bicarbonate (10
percent of the total volume of anesthetic) to reduce the discomfort of
local wound infiltration.
b. Topical Anesthetics
Topical anesthetics, such as EMLA® (eutectic mixture of local anesthet-
ics) Cream (lidocaine 2.5 percent and prilocaine 2.5 percent) can also
be applied to the area of planned local nerve block if sufficient time is
allowed.
c. Pediatric Intensivists or Other Qualified Emergency Physicians
Pediatric intensivists or other qualified emergency physicians can be
invaluable to provide conscious sedation in the emergency department
for children, where wounds are deemed unworthy for the operative
theater and more limited sedation techniques are suspected to be
unsuccessful.
d. Sedation
Most adults will not require sedation for primary closure of a wound
prior to its anesthetization. However, if anxiety is an issue, certain
patients may benefit from parenteral sedation (diazepam) or an
antianxiety/antiemetic medication (promethazine).
2. Extensive Injuries
For injuries with significant tissue avulsion, when underlying osseous or
neurovascular structures are injured or at risk, in polytrauma or life-
threatening injuries, or in instances where conscious sedation for
children is deemed either inappropriate or unavailable, intervention in
the operating theater may be required (and humane).
C. Irrigation and Debridement
The mainstays of successful soft tissue wound management include
irrigation and debridement, particularly in the case of human or animal
penetrating wounds where copious irrigation is essential. Unfortunately,
these steps can generate significant discomfort for the patient. For this
reason, pretreatment local anesthesia is recommended whenever
possible.