The advantages of wound repair under local anesthesia, no matter where the venue, are multiple. The medication, if a narcotic, provides tranquilization and a little euphoria, a decrease in pain tolerance and helps protect against toxicity from the local anesthetic. It can convert an experience that often is fraught with significant apprehension into an easily tolerated or pleasant one.  Prior to medicating an adult, it is important to ascertain whether they have someone to drive them home.

I have an IV started in all patients prior to repairing the wound or wounds, unless IV access is very difficult to obtain. This is sometimes the situation with small children or drug addicts, and intramuscular (IM) administration is necessary.

The almost universal approach for managing patient’s wounds in the ER is to restrain them by wrapping them - terrifying to the child, uncomfortable for the parents, and the accompanying screaming and crying stressful for all those within earshot. By obtaining adequate preop sedation and following the local anesthetic protocol outlined in this chapter, when local protestations can be limited to starting the IV, most of these can be avoided. In children is important to secure the IV well using an arm board.

For adults and children of 8 years of age or older, unless the child is unusually small, I routinely use 10 mg of morphine IV administered slowly. Some adults will volunteer that they respond well to smaller than the usual dose of narcotic and in these patients it is prudent to give a smaller dose. For children  age 3 to 7 I use 1 mg of morphine per year of age. For children under 3, I start with 1 mg and titrate further dosage to attain the adequate sedation. A 2-year-old often will require 3 mg.  If 3 mg doesn’t provide the sedation you want, add 1 mg of Versed. Remember that these agents may require a few minutes to work. Rarely children have such a mind that one cannot achieve the relaxed, cooperative state desired without overdosing them, and they need to be either restrained, or in the case of extensive wound or wounds, done under general anesthesia. Obviously, experience and judgment are involved in these decisions and it is always better to on the conservative side. Use of morphine or Versed antagonists should rarely be necessary. I never saw the need for a Versed antagonist and used Narcan very rarely. [Once in a great while a child who screamed a little loud in recovery from the preop sedation and whom I wanted to discharge.]

This discussion obviously has to do with conscious sedation and leads to later term from the pharmacological exercise referenced above. The past few years, rather elaborate protocols have been almost universally established in hospitals specifying the requirements one must meet to engage in this activity for example, didactic courses or perhaps observation for a set number of cases before allowing to proceed on his or her own.

As a plastic surgery resident in 1960 I was trained to do cleft palette repair under local anesthesia in the days before mechanical monitoring. One determined the level of sedation by carefully observing the breathing pattern, the response the painful stimuli, such as movements and skin color. I am not against all the monitoring devices presently mandated, but deep down feel that if there is a physician involved meets all the prescribed monitoring feels comfortable with this type of sedation, he or she probably shouldn’t be doing it.  Obviously, this comment comes under the [something something] category, but I do think it has some merit. In my experience, when one of the monitoring devices signals something is wrong, it is a problem with the device, rather than with the patient.

Most protocols specify a blood pressure determination every 15 minutes. In pediatric patients, the discomfort involved in this procedure is enough to arouse the patient and it should not be done. Explain this problem in advance to the nurse involved usually resolve the situation. If not, ask to speak in advance to the nursing supervisor. Many protocols such as the one for conscious sedation, are designed by individuals who have little or no practical experience with the routine.

The goal of sedating pediatric patients is to depress their sensorium to the degree that their pain thresholds are significantly blunted rather than to make them drowsy. Local anesthesia can then be obtained essentially painlessly by following the technique outlined. It is important that the child be sedated enough that he or she is not moving. The child does not have to have experienced the full effect of the preoperative sedation before starting the prep.    Gentle cleansing about the wound with warm solution often will have a soothing effect and augment the action of the sedation.

Sedating and obtaining local anesthesia in pediatric patients is almost an art form in itself. Try acquiring competence in this exercise if you can convert almost what is routinely a nightmare episode for the child into one which is much less challenging. Any parent who has gone through the usual routine of restraints and screaming entailed in the repair of a wound will testify to the order of magnitude difference between that experience and the routine referenced above.

Occasionally an adult patient will be concerned regarding becoming a drug addict from one injection of morphine. Usually this apprehension can be dispelled with a little reassurance. If not, the preop sedation can be dispensed with.

As discussed previously, parents or past drug addicts almost always have low pain thresholds and require increased dosages of preoperative medication to secure the desired effect. With the IV, you have the opportunity to titrate the patient.

As noted, determine if an adult has a ride home before preoperative sedation is administered. If they do not, it should be avoided. That is should they should not be driving home for several hours after the IV sedation.