Lidocaine Toxicity Treatment & Management

  • Author: Ruben Peralta, MD, FACS; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Jun 28, 2011
 

Medical Care

If lidocaine toxicity is suspected, stop the injection immediately and prepare to treat the reaction.

Ensure adequate oxygenation, whether by face mask or by intubation.

Benzodiazepines are the drugs of choice for seizure control. Phenytoin is not effective and should be avoided. Succinylcholine is sometimes used to terminate the neuromuscular effects of seizures. Use of succinylcholine requires intubation. Propofol can be used to control seizures but has the risk of potentiating cardiovascular toxicity.

In severe reactions, monitor the cardiovascular system (CVS) and support the patient with intravenous fluids and vasopressors as required. Small boluses doses of epinephrine are preferred. Vasopressin is not recommended.

Hypoxemia and metabolic acidosis may potentiate the cardiovascular toxicity of lidocaine and other local anesthetics. Early control of seizures and aggressive airway management to treat hypoxemia and acidosis may prevent cardiac arrest. Use of sodium bicarbonate may be considered to treat severe acidosis.

Amiodarone is the drug of choice for ventricular arrhythmias due to local anesthetic toxicity.

Cardiac arrest due to lidocaine or other local anesthetic toxicity is a rare but well recognized complication that may occur in cases of large overdose, especially if there is inadvertent intravascular injection. Because local anesthetic toxicity causes no structural cardiac damage, cardiac arrest has a favorable prognosis if circulation can be restored before hypoxemic injury occurs. Aggressive resuscitation is therefore indicated in most cases. Cardiopulmonary bypass has been used effectively to treat cardiac arrest due to local anesthetic toxicity.[3]

The efficacy of lipid infusions to prevent and treat cardiovascular toxicity from local anesthetics has been shown in animal models. Although no blinded studies show efficacy in human toxicity, multiple case reports in human patients have shown favorable results. Use of lipid infusions is currently a Class IIa recommendation.

The above recommendations are largely based on guidelines published by the American Society of Regional Anesthesia.[4]

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Consultations

Consultation with an anesthesiologist can be helpful for difficult airway management. If intubation is not successful, cricothyroidotomy should be performed.

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Contributor Information and Disclosures
Author

Ruben Peralta, MD, FACS  Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Russell F Kelly, MD  Program Director, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Cook County Hospital, Rush Medical College

Russell F Kelly, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold L Manning, MD  Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Dr Karl A Poterack, to the development and writing of this article.

References

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