(February 15, 2023)

Lidocaine is a synthetic local anesthetic of intermediate potency, and one of the most frequently used drugs in the ED.  It has a reversible blocking effect on voltage-gated sodium channels, resulting in two main clinical usages: (i) interrupting nerve impulse propagation to achieve local or regional anesthesia, and (ii) inhibition of cardiac ion channels as a class IB antiarrhythmic drug (10). 

• Lidocaine has a wide variety of specific applications in the ED (1, 2, 3, 6, 14, 20, 22): 

• Antiarrhythmic for ventricular tachycardia

• Local and regional anesthesia for wound repair and fracture closed reductions

• Pain management for severe painful conditions such as renal colic and headache 

• Topical –spray or gel– anesthesia for awake intubation and other procedures such as bladder catheterization 

• Symptomatic treatment of cough

• Transdermal patches to alleviate post-herpetic neuralgia and rib fractures

• A recent double-blinded, randomized controlled trial discouraged use of IV lidocaine for renal colic as it did not show better outcomes than IV ketorolac (13).

Adult dose for local anesthesia (6, 12, 19, 17)

Up to 4.5 mg/kg (max 300mg per dose) subcutaneous infiltration within 2 hours.

Adult dose for ventricular tachycardia (8, 9)

1-1.5mg/kg IV.

Adult dose for local anesthesia (6, 12, 19, 17)
Up to 4.5 mg/kg (max 300mg per dose) subcutaneous infiltration within 2 hours.

• Lidocaine can be diluted with normal saline down to 0.3-0.5% with a similar efficacy. Consider this option in large wounded areas or complex injuries that need procedures longer than 1-2 hours.  

• Lidocaine with epinephrine: 7mg/kg (max 500mg per dose), subcutaneous infiltration.

  • If no premixed solution is available, dilute epinephrine to a concentration of at least 1:100.000.

• Dosing calculator: MDCalc®   - Local Anesthetic Dosing Calculator

Adult dose for ventricular tachycardia (8, 9)

1-1.5mg/kg IV.

• 1 to 1.5 mg/kg; repeat with 0.5 to 0.75 mg/kg every 5 to 10 minutes as necessary (maximum cumulative dose: 3 mg/kg). 

• Consider continuous infusion of 1 to 4 mg/minute or 20 to 50 mcg/kg/minute.

US FDA-Labeled (16, 17, 18)

• Acute management of ventricular arrhythmias occurring during cardiac manipulation such as cardiac surgery

• Life-threatening arrhythmias, particularly those which are ventricular in origin, such as those which occur during acute myocardial infarction

• Local or regional anesthesia by infiltration techniques such as percutaneous injection and regional anesthesia by peripheral nerve block techniques such as brachial plexus and intercostal and by central neural techniques such as lumbar and caudal epidural blocks

• Otic pain (otic drops)

• Ocular anesthesia (ocular drops)

• Topical anesthesia (gels, patches, ointments, topical sprays)

Off-label

• IV pain management (renal colic, headache, other somatic pain, etc)

• Cough alleviation

There are commercially available pre-mixed formulations that combine lidocaine and epinephrine (18). 

• Maximal dose of infiltrated lidocaine when administered with epinephrine: 7mg/kg (up to 500mg within 2 hours). 

• Epinephrine concentration should be diluted  to at least 1:100.000 (usual ampoules of epinephrine in the ED are 1mg/1ml, same as 1:1.000). 

• Studies have shown that lidocaine + epinephrine versus lidocaine alone increases duration of local or regional anesthesia (19).

  • Duration of local anesthesia (12)

    • Lidocaine, subcutaneous: 30-60 minutes

    • Lidocaine + epinephrine, subcutaneous: 120-180 minutes

• Consider lidocaine + epinephrine in complex wounds with expected prolonged repair durations. 

• This mixture is considered safe and is not associated with an increased risk of distal ischemia or necrosis (4). 

• In any case, caution and avoidance of epinephrine infiltration should be considered in cases of vascular insufficiency, overall vasculopathies, Raynaud disease, and other circulatory disorders.

Lidocaine, as a class IB antiarrhythmic agent, is approved by the US-FDA for treatment of ventricular arrhythmias associated with myocardial infarction and cardiac manipulation such as cardiac surgery (16). 

• Cardiac arrest with pulseless ventricular tachycardia (PVT) or ventricular fibrillation (VF): Evidence suggests that antiarrhythmics (amiodarone or lidocaine) provide little survival benefit in refractory PVT or VF (15). The ALPS study (7), a randomized trial of 3026 patients with out-of-hospital VT/VF refractory to initial defibrillation compared IV or IO amiodarone, lidocaine, and placebo and found no differences in survival to hospital discharge or functionally favorable survival in the overall study population, but in subgroup analysis in patients with witnessed collapse, amiodarone or lidocaine resulted in improved survival compared with placebo (28% vs 28% vs 23%).

  • The 2020 ACLS Guidelines recommend administering an antiarrhythmic drug (amiodarone or lidocaine) after the second defibrillation has been executed in the context of PVT/VF cardiac arrest as shown in the resuscitation algorithm (15). 

• Acute myocardial infarction-associated ventricular arrhythmias (VA)

  • According to the 2022 European Society of Cardiology guidelines to prevent and treat MI-associated VA (22),  the first-line treatment includes urgent revascularization, and consider further revascularization if ventricular arrhythmia (VA) develops. Also other measures such as repletion of K+, Mg2+, and starting a beta-blocker should be considered initially. In cases of recurrent hemodynamically stable VA, if the previously mentioned measures fail to control the VA, amiodarone should be considered first. If there still is no response, lidocaine is recommended as an alternative (22). Studies have shown mixed results between amiodarone and lidocaine and there is consensus that more studies are needed to conclude a definite preference (5, 8). 2018 AHA guidelines on “Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death '' do not recommend a specific antiarrhythmic in VA associated with myocardial infarction (8).

  • The 2017 European Society of Cardiology “Guidelines for the Management of Acute Myocardial Infarction presenting with ST-segment Elevation” states over ventricular arrhythmias (VT and VF) that “the typical arrhythmia presentation is unstable, frequently polymorphic, and relatively fast VT, often degenerating into VF. Urgent reperfusion is most important as ischaemia often triggers these arrhythmias. Beta-blockers are recommended if no contraindications exist. Repetitive electrical cardioversion or  defibrillation may be necessary. If there is no sufficient control, i.v. administration of amiodarone is recommended. In case of contraindications to amiodarone, i.v. lidocaine may be considered, although no studies comparing superiority of either drug in STEMI patients are available”. (9).

• For a thorough review of adverse effects and warnings go to lidocaine HCl labeling (16, 17, 18).

• Local Anesthetics Systemic Toxicity (LAST)
  All local anesthetics may cause LAST when toxic plasma levels are reached, most often from accidental intravascular injection during other administration routes. Severity is usually dose-dependent. It provokes cardiovascular and neurologic toxicity:

  • Neurologic toxicity: 

    • Initially presents with lightheadedness, dizziness, followed by visual and auditory disturbances such as difficulty focusing and tinnitus. 

    • Objective signs of neurotoxicity are usually excitatory and include shivering, muscular twitching, facial and distal extremities tremor. 

    • Ultimately and more severe toxicity is manifested by generalized seizures followed by generalized CNS depression state. Seizure activity ceases, and respiratory depression occurs (12).

• Cardiovascular toxicity:
  Local anesthetics have direct actions on the heart and peripheral blood vessels, as well as indirect actions on the circulation by blockade of sympathetic or parasympathetic efferent activity. 

  • Negative inotropism and arrhythmias are caused by decreasing the conduction in Purkinje fibers and cardiomyocytes by prolonging recovery time (12). 

  • It can cause hypotension, bradycardia and finally cardiac arrest (17). 

• Specific treatment for cardiovascular collapse or severe neurologic toxicity secondary to LAST consists of standard advanced cardiovascular life support if necessary and a rapid bolus of lipid emulsion (intralipid 20%) of 1,5 ml/kg (approximately 100ml in adults), followed by an infusion of 0.25ml/kg/min over the next 30-60 minutes. Maximal total dose is 10ml/kg (11). 

Pregnancy (17)

• US-FDA Pregnancy Risk Category B

• Animal reproduction studies at doses up to 6.6 times the human dose have revealed no evidence of harm to the fetus caused by lidocaine HCl. There are, however, no adequate and well-controlled studies in pregnant women.

Lactation (21)

• Lidocaine is considered compatible with breastfeeding in its multiple applications: local anesthetic (dermatological, dental), antiarrhythmic and epidural anesthesia. 

• It is excreted in breastmilk in insignificant quantities and no problems have been observed in infants whose mothers were taking it .

1. Schønemann NK, van der Burght M, Arendt-Nielsen L, Bjerring P. Onset and duration of hypoalgesia of lidocaine spray applied to oral mucosa--a dose response study. Acta Anaesthesiol Scand. 1992 Oct;36(7):733-5. doi: 10.1111/j.1399-6576.1992.tb03554.x. PMID: 1441878.
   Pubmed

2. Rowbotham MC, Davies PS, Verkempinck C, Galer BS. Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. Pain. 1996;65(1):39-44. doi:10.1016/0304-3959(95)00146-8
   Pubmed

3. Chong CF, Chen CC, Ma HP, Wu YC, Chen YC, Wang TL. Comparison of lidocaine and bronchodilator inhalation treatments for cough suppression in patients with chronic obstructive pulmonary disease. Emerg Med J. 2005;22(6):429-432. doi:10.1136/emj.2004.015719
   BMJ (Open Access)

4. Waterbrook AL, Germann CA, Southall JC. Is epinephrine harmful when used with anesthetics for digital nerve blocks?. Ann Emerg Med. 2007;50(4):472-475. doi:10.1016/j.annemergmed.2007.03.004
   Pubmed

5. Piccini JP, Schulte PJ, Pieper KS, et al. Antiarrhythmic drug therapy for sustained ventricular arrhythmias complicating acute myocardial infarction. Crit Care Med. 2011;39(1):78-83. doi:10.1097/CCM.0b013e3181fd6ad7
   Pubmed Central (Open Access)

6. Golzari SE, Soleimanpour H, Mahmoodpoor A, Safari S, Ala A. Lidocaine and pain management in the emergency department: a review article. Anesth Pain Med. 2014 Feb 15;4(1):e15444. doi: 10.5812/aapm.15444. PMID: 24660158; PMCID: PMC3961016.
   Pubmed Central (Open Access)

7. ALPS: Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2016;374(18):1711-1722. doi:10.1056/NEJMoa1514204
   NEJM (Open Access)
   Article compendium The Bottom Line - ALPS

8. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2018 Sep 25;138(13):e419-e420]. Circulation. 2018;138(13):e272-e391. doi:10.1161/CIR.0000000000000549
   Circulation (Open Access)

9. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. doi:10.1093/eurheartj/ehx393
   European Heart Journal - ESC European Society of Cardiology (Open Access)

10. Hugh C, Hemmings JR, Talmage DE. Pharmacology and Physiology for Anesthesia: Foundations and Clinical Application, 2nd Edition. Philadelphia, PA: Elsevier, Inc; 2019.
    Elsevier

11. Nelson LS, Howland MA, Lewin NA, et al. Goldfrank’s Toxicologic Emergencies. 11th edition. New York, NY: McGraw-Hill Education; 2019.
    McGraw-Hill

12. Gropper MD. Miller’s Anesthesia. 9th edition. Philadelphia, PA: Elsevier; 2020.
    Elsevier

13. LIDOKET: Motov S, Fassassi C, Drapkin J, et al. Comparison of intravenous lidocaine/ketorolac combination to either analgesic alone for suspected renal colic pain in the ED. Am J Emerg Med. 2020;38(2):165-172. doi:10.1016/j.ajem.2019.01.048
    Pubmed
    Article compendium and discussion REBELCast - LIDOKET

14. Johnson M, Strait L, Ata A, et al. Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?. Am Surg. 2020;86(9):1153-1158. doi:10.1177/0003134820945224
    Pubmed

15. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468. doi:10.1161/CIR.0000000000000916
    Circulation (Open Access)

16. NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: lidocaine hydrochloride injection. Updated in January 2020, accessed February 2, 2023. 

DailyMed (antiarrhythmic label)

17. NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: Lidocaine hydrochloride - lidocaine injection, solution. Updated in March 2021, accessed 2 February 2, 2023.
    DailyMed (local anesthesia label)

18. NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: Lidocaine Hydrochloride and Epinephrine Bitartrate Injection, Solution. Updated in December 2021, accessed 2 February 5, 2023.
    Dailymed (lidocaine + epinephrine formulation label)

19. Kitahara LBW, Silva VPD, Peres G, Miot HA, Schmitt JV. Efficacy of different concentrations of lidocaine and association of vasoconstrictor in local infiltration anesthesia in adults. An Bras Dermatol. 2021;96(5):623-625. doi:10.1016/j.abd.2020.08.021
    Anais Brasileiros de Dermatologia (Open Access)

20. Abdulqawi R, Satia I, Kanemitsu Y, et al. A Randomized Controlled Trial to Assess the Effect of Lidocaine Administered via Throat Spray and Nebulization in Patients with Refractory Chronic Cough. J Allergy Clin Immunol Pract. 2021;9(4):1640-1647. doi:10.1016/j.jaip.2020.11.037
    Pubmed

21. APILAM (Association for promotion of and cultural and scientific research into breastfeeding). (2002). e-lactancia. Lidocaine Hydrochloride. Updated May 2022. Accessed 09 February 2023.
    E-lactancia

22. Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022;43(40):3997-4126. doi:10.1093/eurheartj/ehac262
    ESC (Open Access)