Algorithm for topical anesthetic use* in children

IV: intravenous; LP: lumbar puncture.
* For example:

• Lidocaine/prilocaine 2.5%/2.5% (EMLA).
• Liposomal lidocaine 4% (LMX₄).
• Tetracaine gel (40 mg tetracaine per 1 g of gel). Tetracaine gel is an ester-type local anesthetic that is not available in the USA.

¶ For patients undergoing an emergency procedure through intact skin, needle-free delivery of lidocaine (J-tip) or infiltrative anesthetic is suggested. For patients with skin that is not intact, local infiltration or topical anesthesia with a combination of lidocaine, epinephrine, and tetracaine (LET) may be used. For patients with an allergy to amide or ester anesthetics, refer to UpToDate topics on allergic reactions to local anesthetics.
Δ Methemoglobinemia is only a contraindication for EMLA. Refer to UpToDate topics on clinical features, diagnosis, and treatment of methemoglobinemia.
◊ Topical anesthetic should be applied as soon as the need for a procedure is evident. Refer to UpToDate topics on topical anesthetics in children.