Resident Manual of Trauma to the Face, Head and Neck

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.

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