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LP_collect copyA 9 year-old patient presents with a headache and fever after swimming, along with subjective neck stiffness. Meningitis was of concern especially because the serum WBC count was 25,000 and other inflammatory markers were elevated. Because the patient’s mother had an unpleasant experience with an epidural during childbirth, she adamantly opposed the idea of a lumbar puncture (LP). 

Trick of the Trade: EMLA for lumbar puncture procedures

After bringing up the notion of using EMLA to reduce the needlestick pain, the patient’s mother eventually agreed. Using a portable TV as a distraction technique in addition to the EMLA, we performed the procedure without the child aware of the needle puncture. Fortunately, all CSF studies were normal and the patient was discharged home. Just as importantly, we won over the trust of the mom in our ability to deliver high-quality and compassionate care. 

While EMLA use for painful pediatric procedures has been widely reported as safe in the literature in a variety of clinical settings, it is often not considered amidst the chaos of a busy emergency department. In a large study of emergency physicians and pediatricians, Gorchynski and McLaughlin showed that providers typically only administer local anesthetic prior to lumbar puncture (LP) 66% of the time in infants.[1]

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What is EMLA?

EMLA cream is composed of 2.5% lidocaine and 2.5% prilocaine. It is preservative free, for topical use only, and should be applied under an occlusive dressing on intact skin. It’s an incredibly safe medication with contraindications only being known local anesthetic allergy or susceptibility to methemoglobinemia. In addition, it can be used on neonates, provided they are greater than 37 weeks of gestational age.[2] Below is a table from the EMLA package insert regarding dosing by age/weight:

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The use of EMLA has been well studied especially regarding LPs. In a prospective, randomized, double-blind and placebo-controlled trial, it was demonstrated that EMLA (1 g applied 60-90 min before the procedure) resulted in lower heart rates and mean behavioral scores during needle insertion without any complications or difference in procedural success.[3]

Does EMLA application delay care?

Although the time delay of 60-90 minutes is often cited as a reason not to use EMLA, there is often an inherent delay between the decision to do the procedure and its actual commencement. Oftentimes, this inevitable delay nears that the time for EMLA to take effect. As long as it is applied early in the clinical course, this effect is negligible. One solution is to apply it early if there’s any doubt, as it can always be removed if the decision is made not to proceed. 

As an alternative to EMLA, 4% liposomal lidocaine has been substituted at some hospitals, as it acts within 30 minutes.[4]

Not just for kids

Don’t forget that EMLA can also be applied to adults for LPs as well. Not only does it reduce pain and improve satisfaction, but it also makes it easier for physicians to perform the procedure.  

References

  1. Gorchynski J, McLaughlin T. The routine utilization of procedural pain management for pediatric lumbar punctures: are we there yet? J Clin Med Res. 2011 Jul 26;3(4):164-7. doi: 10.4021/jocmr584w. PMID: 22121399
  2. EMLA package insert
  3. Kaur G, Gupta P, Kumar A. A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med. 2003 Nov;157(11):1065-70. PMID: 14609894.
  4. Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics. 2002 Jun;109(6):1093-9. PMID: 12042548.
Jeff Wiswell, MD

Jeff Wiswell, MD

Ultrasound Fellow
Department of Emergency Medicine
University of California, Davis (UCD)