Scott Hirsh, DPM, DABPS describes the topical anesthesia options available for the painful wound. Dr Hirsh discusses the benefits of these agents for the perception of pain and ultimate improvement of the patient experience.
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Scott Hirsh, DPM
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Male Speaker: We know that wound pain is a problem and probably an unsolved or unmet problem not so much for DFUs which for the most the part are neuropathic and usually painless. But especially DFUs, a typical types of wounds are painful and we don’t have enough talks on pain in large family wounds or wounds in general for that matter. Our next presenter is going to talk about the use of topical anesthetics and analgesics for the control of wound pain. Please welcome Dr. Scott Hirsh to the podium to talk about this very, very important subject.
Scott Hirsh: Alright. Well, good afternoon everybody. It’s a pleasure to be here at the Desert Foot Conference. My name is Scott Hirsh, I’m a private practice podiatrist from the Cleveland, Ohio area. I might do have to disclose I am a consultant to the Gebauer Company who manufactures topical anesthetic products. During today’s lecture we are going to discuss topical anesthetics for painful open wounds and see how these products could change patient perception and improve the overall patient experience. Perception is defined as the organization, identification, and interpretation of sensory information in order to fabricate a mental representation to the process of transduction. Similar to this cat looking in the mirror and perceiving himself as this big fierce lion, we like our patients to perceive our office is not a place that’s going to cause more pain or rather eliminate pain in pathology. All perceptions involve signals in the nervous system which in turn result from physical stimulation at the sense organs. According to Saks and John there are three components to perception. You have the perceiver, the target, and the situation. The perceiver is the individual who becomes aware of a problem or something is going on, in this case would be the patient. We have the target as the person being perceived or judged, in this case would be the doctor. We have the situation, it’s not the guy from that show the “Jersey Shore” but rather the encounter between the doctor and the patient. Another hot topic in medicine right now is patient experience. Big medical groups, multispecialty groups, large hospital systems are spending a lot of money on figuring the option or way to create a perfect patient experience. Let’s begin with the patient’s first step into the office and continues to the time that the patient leaves. It’s a step-by-step process in making the patient feel they’re cared for and confident about their care. This begins as you enter the waiting room, you wanted it to be spacious if you can, plenty of seats not only for the patient but the patient’s caregivers or family members that bring them. You could have chairs on the waiting room for easier geriatric population to get up and down. One, have a positive first encounter with the receptionist, you want to have short wait times, you should know your case as a physician and how many patients you could optimally see within your set office hours. We’re going to talk about today mostly as decreasing stress by using proper products to reduce pain and improve your office or clinic’s efficiency. Study suggest that physicians’ offices one of exude four psychological elements for an optimal patient experience. These are confidence, integrity, pride, and passion. Confidence is that the patient can trust the doctor to deliver on his promises. Integrity, you want to treat patients fairly and you’ll satisfactory try to resolve any of the problems. Pride, is a degree to which patient feel good about the office. Passion, you want your patient to feel the office is irreplaceable, an integral part of the medical care. Today, we’re going to talk about this or creating a better patient perception, increasing patient satisfaction by controlling pain management to the use of topical anesthetics. Topical anesthesia can be defined as a superficial loss of sensation in the mucous membranes or the skin produced by a direct application of a local anesthetic. It’s also called surface anesthesia. Why do you want to use topical anesthesia? You want to use it to increase patient satisfaction by decreasing pain, decrease patient stress levels, the ease of applying topical anesthetics and the variety of usages. Pain is extremely relevant to us as physicians and the number one reason that patients seek consultation in the United States. Duration of pain is usually transitory and it usually lasts only until the noxious stimulus is removed or the underlying tissue damage or pathology has healed. Terms associated with describing the duration of pain or acute and chronic as we know with acute being your short acting quickly resolving pain and chronic being your longer acting pain, usually greater than six months in duration.
Different types of pain include nociceptive, neuropathic, phantom, and psychogenic. Nociceptive most directly relates to our topic today so we will discuss that over the next couple of slides. We have neuropathic which affects the somatosensory systems which are seen in our diabetics when they usually described pain as burning or tingling. We have phantom pain which is pain from part of a body that has been lost or from which the brain no longer receive signals. These are seen in our patients who have had amputations and study suggests that large numbers of these 82% in upper extremity and 54 in lower extremity and we’ll have some type of phantom pain at sometime. Finally we have psychogenic pain which is pain caused, increased, or prolonged by mental, emotional, or behavioral factors and this could be an example of a headache or a backache. Nociceptive pain is pain caused by stimulation of the peripheral nerve fibers that respond only to stimuli a protein or exceeding harmful intensity. That’s classified according to the mode of noxious stimulation. We have thermal, mechanical, and chemical. With thermal being your temperature-driven one with something becoming too hot or too cold. Mechanical being more physical in nature, something like crushing or tearing or something that we would produce by a surgery. Chemical, an example the iodine in a cut. Our body perceives pain through a five step pain pathway. First, you have signal transduction at the peripheral receptor site, followed by signal conducting along the peripheral nerves, pain modulation at the level of spinal cord, pain perception at the supraspinal site, and then the associated sensations, emotional reactions in affected state. Topical anesthetics effective pain pathway by reversibly blocking nerve conduction near the site of administration thereby producing a temporary loss of sensation to a limited area. Here’s our typical picture of a neuron, we’re going to have your signals are going to receive by the dendrites going to the cell body, the nucleus, the axons, and then they’re going to be transmitted through the axon terminals. Here’s the illustration depicting the pain pathway. Once again there’s going to be some form of noxious stimuli whether it be thermal, mechanical, or chemical going to level the peripheral receptor sites, to the peripheral nerves, to the spinal cord, up to the supraspinal levels and the brain telling your body that we have something going on. Another reason why you want to use topical anesthetics is to decrease stress levels. Trypanophobia is the extreme fear of medical procedures involving injections or hypodermic needles. It is officially recognized in 1994 in the DSM 4. There is estimated 10% of the United States adults are trypanophobic and it’s much more likely that number is much higher because most people who have such a fear of a needle will not seek medical attention and therefore those cases are undocumented. Different types of needle phobia include vasovagal, associative, resistive, hyperalgesic and vicarious. Vasovagals is the most common one, the one we’ll see in office most commonly. It is when a patient has a rapid increase in blood pressure then a dramatic plunge in blood pressure. Physiological signs include sweating, pallor, nausea, and vomiting. Here’s the list of some famous people with trypanophobia. Among them are NBA star Derrick Rose and Late Night talk show host Conan O’Brien. Again, why topical anesthesia. You want to use this for its ease of application. We can achieve topical anesthesia by the following methods. Simply applying a cream or liquid through iontophoresis or a topical spray or vapocoolant. Also for its variety of usages. Many of us are very comfortably using topical anesthetics for pre-injection anesthesia and then you could as well for minor surgical procedures. I was saying a second ago is that we’re all comfortably using for pre-injection anesthesia. It could be used before you inject things for neuromas, plantar fasciitis, bursitis, capsulitis, basically anything that ends in itis, arthritic conditions and podiatric blocks. One of the things I want to emphasize today is using a topical anesthetic as a stand alone form of anesthesia for certain minor surgical procedures. This can include incision and drainage of a bursa, paronychia or abscess, ingrown toenails, aspiration of lesions such as ganglionic cyst, incision and removal of superficial foreign bodies, excision of skin growth or skin tags, where we’re going to focus on today is debridement of open wounds. Different forms of topical anesthesia that we can use are creams, we’ll discuss EMLA today, topical solutions, we’ll talk about lidocaine 4% and spray or topical vapocoolant, and we’ll talk about Pain Ease. First, we’ll talk about EMLA, it’s a mnemonic for eutectic mixture of local anesthetics. The local anesthetics in this case were lidocaine and prilocaine, both was 2.5%. It works by relieving pain of normal intact skin and numbing skin to pain from injections and other medical procedures. Lidocaine and prilocaine are both MI type local anesthetics.
How it works is producing a transient and biphasic vascular response involving initial vasoconstriction, followed by vasodilation at the application site. Next on the slides are just some study showing the efficacy of EMLA for start debridement of painful open wounds. The first one is from the European Journal of Emergency Medicine. This is a really large study that spent over six years and encompass 1,084 patients. The medicine was applied for 45 to 60 minutes and all the patients but three out of 1,084, the analgesic was adequate for debridement. The only small side effects which was found in 12 patients which is only about 1.1% was burning at the application site and then subside within 15 to 20 minutes. A next study comes from the Journal of Wound Care. This was a multicenter, double-blind, placebo-controlled parallel group study. There’s a 101 patients in the study, 51 received EMLA and 50 received a placebo. It was applied for 30 minutes under occlusion and it significantly reduced the pain of debridement compared with the placebo. The onset depth and duration of thermal analgesia depends on the duration of application for this product. For minor surgical procedures, the product should be applied under occlusion for at least one hour. Again, this is for minor surgical procedures and is recommended 30-minute application for open wounds or ulcer debridement. The answer to that should be 30 to 60 minutes, duration can be up to five hours, depth of penetration from four to five millimeters, and is approved for ages 37 weeks gestational and above. Counter indications for patients with unknown history of sensitivity to local anesthetics of the MI type and should not be used in rare patients with congenital or idiopathic methemoglobinemia. This is usually seen as a side effect with prilocaine. Precautions include repeated doses may increase blood levels of lidocaine and prilocaine. You want to avoid contact with the eyes, caution patients with hepatic disease because of their inability to metabolize local anesthetics normally. Drug interactions, this product should be used with caution in patients receiving Class I antiarrhythmic drugs, because the toxic effects were additive and possibly synergistic. It’s a pregnancy category B drug and lidocaine and probably prilocaine are excreted in human milk so if we want to avoid in mothers that are breastfeeding. Side effects are abnormal skin sensation, burning, change in hot or cold sensation, pale skin, and redness or swelling at the application site. Here’s just how to properly apply the medicine. You’re going to put a generous portion of the medicine on the area where you’re going to do your minor surgical procedure or your open wounds or ulcer debridement. You’re going to apply it under occlusion, something like a Tegaderm for, once again, for minor surgical procedures. It’s going to be for about 60 minutes and for an open wound about 30 minutes. You’re going to remove your occlusive dressing, wipe off your product, sterilize the area and then begin either your minor surgical procedure or your debridement of your open wound. We’ll now just quickly talk about topical lidocaine solution 4%. Some general information about lidocaine is that approximately 95% metabolized by the liver, half life of 90 to 120 minutes. It may be prolonged in patients with hepatic impairment or congestive heart failure. Mechanism of action, lidocaine, hydrochloride solution stabilizes the neuronal membrane by inhibiting the ionic fluxes require for the initiation and conduction impulses thereby affecting local anesthetic action. It has a rapid onset of action and an intermediate duration of efficacy. Some side effects, they’re usually temporary and happen at the site of application include redness, stinging, and swelling. How do you want to apply this, you want to cleanse the open wound, you want to have your instrumentation ready for debridement, impregnate a four by four gauze with the 4% topical lidocaine solution, place the gauze directly over the wound for approximately three to five minutes at first then begin your debridement. If the patient still feeling pain and you don’t like him, you can continue. And if you do like him then you could just simply place the medicine on there for a little bit longer. Finally, we’re going to talk about Pain Ease which is the topical vapocoolant spray. It’s a topical skin refrigerant that creates an instantaneous cooling effect on the surface of the application site by the immediate evaporation of the product from the skin surface. The coolness created by the spray decreases the nerve conduction velocity of the C fibers and the A delta fibers that make up the peripheral nervous system thus interrupting the nociceptive inputs to the spinal cord. Is FDA cleared medical device indicated for injections, IV starts some venipuncture, minor surgical procedures, and open wounds and intact mucus membranes. Contraindications are individuals with a history of hypersensitivity to Pain Ease and as skin irritation develops you want discontinue the use.
Risk and safety information, published clinical data supports the use in ages three years or older through external use only. You don’t want to store above a 120 degrees and you don’t want to place near fire, flame, or hot surfaces. You do not want to spray in anyone’s eyes, continuous sensitization may occur in rare cases. Freezing can occasionally alter skin pigmentation, and over spraying may cause frost bite. Precautions again, inhalation should be avoided, you do not want to use on large areas of damage skin, punctured wounds, animal bites, or serious wounds. We also want to use in caution with patients with severe circulatory conditions or poorly controlled diabetics. Some of the beneficial qualities are there’s no systemic absorption. It is nontoxic by inhalation, it is noncarcinogenic, and it is safe to use during pregnancy, I spelled wrong there, when use as directed. Also proper usage for this product, you want to have our instrumentation ready for surgical debridement. Swab the treatment area with an antiseptic, you want to spray continuously from three to seven seconds from a distance of three to nine inches away, you want to spray to the area until the skin just turns white or blanches, you don’t want to freeze the skin. Then you could begin your surgical debridement. You get approximately 50 applications per can and the cost is relatively cheap at 40 to 50 cents. It also passed the microbial limit test with accordance with the USP which means that it will not introduce any new bacteria such as Staph. aureus, E. coli, salmonella, or pseudomonas. The product is not flammable, and it could be use in conjunction with laser equipment or cautery. You just want to make sure that the product is completely evaporated before you use those. Also it can be reapply, so if you have a large wound that you’re using this for, if it’s seems like the patient is having a little bit of pain , you can just reapply it. There also going to be a positive economic impact to using topical anesthesia. Once again we’re going to have increased patient satisfaction because we’re not going to have to use that needle, take it out, and you could distort wound edges with that and you can create new openings. We also going to have a better time management which can lead to an increased patient load which has a possibility into a better increased revenue string for you. Again, increase patient satisfaction by using this, we can have a call me effect on patients, to have topical anesthesia prior to performing the procedure, and eliminates the fear of needles for minor surgical procedures which again is also a safety benefit for both the patient and the doctor. Better time management increase patient load by using this product for minor surgical procedures, you don’t have to waste time loading up anesthesias and syringes. You don’t have to go over that cabinet, take the bottle out, wipe the top and down, an 18-gauge needle, draw it up, if it’s lidocaine then the same thing for Marcaine, et cetera. You don’t have to wait for the anesthesia to take effect and you don’t have to tie up a room while waiting. A lot of people for certain minor surgical procedures or debridement of open wounds may like this, they’ll go ahead, they’ll numb the patient up and then they’ll have to wait for it to take effect so they leave the room. Right here is just a possible increased revenue string that could be seen, it’s based on 250-day per year calendar working year. On the left is one patient a day, three patients in five and you’re able to add this to your increased efficiency and on right is just your per patient revenue of an average of $50 per patient of 75 and a 100. You could see there’s a chance it could be profitable for your office or clinic setting. I just want to hope that through today’s lecture, we saw some different options that can be used for topical anesthesia for painful wounds. You can see by utilizing these products that we could help change patient perception and increase overall patient experience. Thank you very much for your time and hope you enjoy the rest of this great conference.