Guidelines for Use of Topical Lidocaine in the ED

Topical anesthetics should be considered in any patient who has a high likelihood of undergoing a non-emergent invasive procedure on intact skin in the ED. These include the following:
 • Intravenous line placement or venipuncture
 • Lumbar puncture
 • Abscess drainage
 • Joint aspiration
Discussion with parents should bring up the following issues:
 • Topical lidocaine does not provide complete pain relief
 • Some patients may require a procedure before topical lidocaine reaches its full effectiveness (see below)
 • Discuss with the parents how they feel the patient will tolerate the topical lidocaine application, in terms of anticipation of the procedure as well as sensory integration disorders
 • Emergent need for IV access
 • Allergy to amide anesthetics
 • Nonintact skin
 • EMLA only: Recent sulfonamide antibiotic use (trimethoprim-sulfamethoxazole, erythromycin-sulfisoxazole); congenital or idiopathic methemoglobinemia
The topical anesthetic dose should be lower for patients <12 mo old or weighing <10 kg
Placement of topical lidocaine:
 • Intravenous line placement
  Topical lidocaine should be placed in at least 2 sites over veins amenable to placement of an IV line, preferably judged by the nurse placing the IV line.
  Care should be taken to avoid mucous membrane contact or ingestion
 • Lumbar puncture
  Placement of topical lidocaine for lumbar puncture should be considered as soon as the decision is made to perform a lumbar puncture; accurate placement may require consultation with the clinician performing the procedure
   Liposomal topical lidocaine reaches full effectiveness in 30 min, heated topical lidocaine in 20 min, EMLA reaches full effectiveness in 60 min.