Trick of the Trade: EMLA for Lumbar Punctures

Trick of the Trade: EMLA for Lumbar Punctures

2016-11-11T19:03:55+00:00

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

Attending physician
Department of Emergency Medicine
Mayo Clinic Health System
  • amywalsh

    Any reason other topical anesthetics like LET couldn’t be used as well?

    • Jeff Wiswell

      Hi Amy–my understanding is that LET is for non-intact skin, but I can’t find any good data or package inserts to verify this, as most of it is made via compounding pharmacies from what I can tell

      • Michelle

        Definitely LET is used for non-mucosal lacerations (non-intact skin). Here’s an old publication on topical anesthetics from AAFP: http://www.aafp.org/afp/2002/0701/p99.html

      • amywalsh

        Oops, I meant LMX. Though I have tried LET in a pinch at my rural site prior to IV starts for kids. I guess I’ve never been in the room to witness if it did any good.

        • Michelle

          LMX-4 = Liposomal 4% lidocaine = used to be called ELA-Max. It’s a reasonable alternative if you have it. Shorter time to onset (30 min). See reference #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.
          http://www.ncbi.nlm.nih.gov/pubmed/?term=12042548

  • Justin Cook

    Ever try a J-Tip? I have no financial stake whatsoever in this, but this device provides a single, fast, jet injection of lidocaine, and it leaves a little umbilicated mark, perfect for LPs. Analgesia is immediate. Great for IV placement in kids primarily, but I love it for LPs.

    • Jeff Wiswell

      Hi Justin–totally agree. J-Tips rock, although we don’t currently have them at my hospital right now. One of the issues I’ve noticed with them, though, is that they tend to be really scary in the 2-3 year-old crowd because of the noise and amount of fluid that gets shot out.

      • Michelle

        Haven’t tried the J-tip but glad to know of alternative anesthetic options.

  • Justin Cook

    Also, a 22 Ga Whitacre or pencil-tip needle (for post-LP headache minimization) is tough to get through skin without first puncturing it with a larger gauge needle–I use an 18 or 20 Ga needle to get through skin only after anesthesia sets in, whether using EMLA or J-Tip.

    • Tae Kim

      When using a Whitacre, I use the same puncture wound that I made with the 25 ga. injection of 1%lido with epi for anesthesia. Reduces the need for another needle, another puncture wound, and makes for easier Whitacre puncture.

  • Justin Cook

    Can’t help myself here, sorry: try a J-Tip (or EMLA, if there’s time) on your next ultrasound-guided nerve block. For patients who are really afraid of needles, it’s a great adjunct.

  • TChanMD

    Sad part is… now that we have a dedicated Peds hospital, we stopped stocking EMLA/Ametop/etc.. 🙁 #Adultshavepaintoo

    • Michelle

      That indeed is sad…

  • Nilesh Patel

    What dose and time frame of application do you recommend for adults?

    • Jeff Wiswell

      Same as kids–60 min is more than enough

    • Michelle

      Looks like the EMLA insert above says 20g for body wt>20 kg, although rarely will you need that much. It’ll be more like just 1-2g depending on the size of the area you want to anesthetize. Remember to place a dressing cover over it, such as a Tegaderm, to enhance absorption.

      • Jeff Wiswell

        Michelle makes a key point–I ordered it this week for an abscess I&D and found that the nurse just painted it on, so it had no effect because it ran all over the place

  • Chris Cole

    Great idea if you’re going down the “treat now, LP later” path, or the LP is non-urgent, but if you’ve decided to do an LP in ED, you’re not waiting 2 hours for the EMLA to take effect to do it (well, I’m not). Other options include amethocaine gel or cream (works faster) or simply using ice to chill & numb the skin (though if it’s a child, they may be even less enthused about the ice than they are about a needle).

    If they’re too big & strong to use brutacaine, then bite the bullet and use procedural sedation. Unless you really don’t need/want the CSF in ED, in which case slap the EMLA on for the benefit of the inpatient team doing it later.

    • Joe

      Try the Synera topical patch. It has lidocaine/tetracaine combo and works in 20-30 minutes prior to LP or other needle sticks.