eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Lidocaine: Treatment & Medication

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
Coauthor(s): Karl A Poterack, MD, Consulting Staff, Department of Anesthesiology, Mayo Clinic Scottsdale; Sarah C Langenfeld, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink
Contributor Information and Disclosures

Updated: May 30, 2008

Treatment

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.
  • Anticonvulsants such as benzodiazepines and barbiturates (diazepam 5-10 mg, thiopental 50-100 mg) are the drugs of choice for seizure control. Phenytoin is not effective and should be avoided. Succinylcholine is sometimes also used to terminate the neuromuscular effects of seizures. Because succinylcholine paralyzes all muscles, the patient requires intubation.
    • In severe reactions, monitor the cardiovascular system (CVS) and support the patient with intravenous fluids and vasopressors as required.
    • Metabolic acidosis may develop, and the use of sodium bicarbonate can be considered, although, as in other instances of acute metabolic acidosis, this is controversial.

Consultations

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

Medication

The goals of therapy in CNS lidocaine toxicity are to secure a patent airway and to terminate the neuromuscular and cerebral manifestations of seizures.

Barbiturates

These agents terminate seizure effects.


Thiopental (Pentothal)

Depresses consciousness and diminishes or terminates seizures. Depresses reticular activation system, perhaps by decreasing rate of dissociation of inhibitory neurotransmitter GABA from its receptors.

Adult

50-100 mg IV initially

Pediatric

1-2 mg/kg IV

Increased respiratory and cardiac depression in presence of other CNS depressants

Documented hypersensitivity (rare), porphyria, presence of severe hypovolemia or unstable hemodynamics, lack of familiarity with drug, inability to manage airway

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Only those skilled in airway management should use thiopental

Benzodiazepines

These agents terminate seizures. By binding to specific receptor site, these agents appear to potentiate effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.


Diazepam (Valium)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Diminishes or terminates seizures. Individualize dosage and increase cautiously to avoid adverse effects.

Adult

5-10 mg IV

Pediatric

0.25 mg/kg IV

Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs; cisapride can significantly increase toxicity

Documented hypersensitivity, acute narrow-angle glaucoma, open-angle glaucoma (unless receiving appropriate therapy)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Seizure activity may recur; may interact with other sedatives to produce profound depression of consciousness and cardiovascular depression


Midazolam (Versed)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Diminishes or terminates seizures. Shorter acting and more potent than diazepam. Individualize dosage and increase cautiously to avoid adverse effects.

Adult

2-5 mg IV

Pediatric

0.025-0.1 mg/kg IV

Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs

Documented hypersensitivity, acute narrow-angle glaucoma, open-angle glaucoma (unless receiving appropriate therapy)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Seizure activity may recur; may interact with other sedatives to produce profound depression of consciousness and cardiovascular depression

Muscle relaxants

Facilitate airway control and terminate neuromuscular manifestations of seizures.


Succinylcholine chloride (Anectine, Quelicin)

Causes paralysis of airway and respiratory muscles; apnea ensues. Establishing and maintaining an airway and ventilation are mandatory prerequisites.

Adult

1-2 mg/kg IV

Pediatric

Administer as in adults
Most experts recommend against use in pediatric patients whenever possible because of case reports of death with unsuspected muscular dystrophy

Duration may be prolonged in pregnant patients, those with liver disease, and those who have received nondepolarizing muscle relaxants

Documented hypersensitivity, hyperkalemia, history of recent burn or crush injury, malignant hyperthermia, muscular dystrophy, neuromuscular disease, stroke

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Only those skilled in airway management should administer; establishing and maintaining an airway and ventilation are mandatory prerequisites

More on Toxicity, Lidocaine

Overview: Toxicity, Lidocaine
Differential Diagnoses & Workup: Toxicity, Lidocaine
Treatment & Medication: Toxicity, Lidocaine
Follow-up: Toxicity, Lidocaine
References
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References

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  4. Challapalli V, Tremont-Lukats IW, Mc Nicol. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev. CD003345.

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  14. Odaka Y, Takahashi T, Yamasaki A, et al. Prevention of halothane-induced hepatotoxicity by hemin pretreatment: protective role of heme oxygenase-1 induction. Biochem Pharmacol. Apr 1 2000;59(7):871-80. [Medline].

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  18. Tremont-Lukats IW, Challapalli V, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetics to relieve neuropathic pain: a systematic review and meta-analysis. Anesth Analg. Dec 2005;101(6):1738-49. [Medline].

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Further Reading

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Keywords

lidocaine toxicity, local anesthetic toxicity, lidocaine poisoning, adverse anesthesia reaction, lidocaine overdose, anesthetic overdose, local anesthetic reaction, CNS lidocaine toxicity, anesthetic reaction, anesthesia toxicity

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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 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.

Coauthor(s)

Karl A Poterack, MD, Consulting Staff, Department of Anesthesiology, Mayo Clinic Scottsdale
Karl A Poterack, MD is a member of the following medical societies: American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Sarah C Langenfeld, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink
Sarah C Langenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Harold L Manning, MD, Associate 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.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint 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, Academic Affairs, 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, 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

 
 
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