Classification
Class IB antiarrhythmic
Local anesthetic
Indications
PCP: ONLY under direction of an on-scene ACP or higher Local anesthetic during ADULT (12 years old and greater) intraosseous cannulation
ACP: Control of ventricular arrhythmias (including ectopy, brief or sustained ventricular tachycardia, and ventricular fibrillation)
ACP: Local anesthesia during intraosseous cannulation
ACP: Local anesthesia during awake intubation
Contraindications
- Allergy or hypersensitivity to lidocaine
- For systemic (IV/IO) administration, including rhythm control and IO anesthesia:
- Third-degree AV block
- Ventricular escape rhythms
- Wolff-Parkinson-White syndrome
Consider alternative agents in patients with congestive heart failure. CliniCall consultation recommended to discuss care planning options in these cases (1-833-829-4099).
NB: some sources report that lidocaine use is contraindicated in second-degree AV blocks. These rhythms are functionally supraventricular, and in the post-arrest context, the benefits of lidocaine would be likely to outweigh the theoretical risks.
Adult dosages
PCP: ONLY under direction of an on-scene ACP or higher Local anesthesia during intraosseous cannulation (in conscious patients)
- Administer lidocaine, 40 mg
- Instill the lidocaine slowly, over 120 seconds, making sure to administer the appropriate amount of lidocaine through the extension; allow it to dwell in the bone marrow cavity for 60 seconds
- Slowly flush the IO with 5-10 mL normal saline following the administration of lidocaine
ACP: Ventricular rhythm control
- 1.0-1.5 mg/kg IV bolus
- May repeat at 0.5-1.0 mg/kg; total maximum dose 3 mg/kg
ACP: Local anesthesia during intraosseous cannulation (in conscious patients)
- Administer lidocaine, 40 mg
- Instill the lidocaine slowly, over 120 seconds, making sure to administer the appropriate amount of lidocaine through the extension; allow it to dwell in the bone marrow cavity for 60 seconds
- Slowly flush the IO catheter with 5-10 mL normal saline following the administration of lidocaine
ACP: Local anesthesia for awake intubation
- Attach lidocaine preload to mucosal atomizer device and directly spray the surface of the tongue, soft palate, posterior pharynx, and tonsillar pillars
- Employ a "spray as you go" technique and assess for degree of anesthesia
- There is no consensus on a maximum permissible dose; avoid exceeding 5 mg/kg topically where possible
Pediatric Considerations And Dosing
Follow weight-based dosing
ACP: Ventricular rhythm control
- 1.0-1.5 mg/kg IV bolus
- May repeat at 0.5-1.0 mg/kg; total maximum dose 3 mg/kg
ACP: Local anesthesia during intraosseous cannulation (in conscious patients)
- 0.5 mg/kg; maximum 40 mg infused over 120 seconds
- Instill the lidocaine slowly, over 120 seconds, making sure to administer the appropriate amount of lidocaine through the extension; allow it to dwell in the bone marrow cavity for 60 seconds
- Slowly flush the IO with 2-5 mL normal saline following the administration of lidocaine
ACP: Local anesthesia for awake intubation
- Attach lidocaine preload to mucosal atomizer device and directly spray the surface of the tongue, soft palate, posterior pharynx, and tonsillar pillars
- Employ a "spray as you go" technique and assess for degree of anesthesia
- There is no consensus on a maximum permissible dose; avoid exceeding 5 mg/kg topically where possible
Mechanism Of Action
As a sodium channel blocker, lidocaine decreases the duration of the action potential by shortening the period of repolarization.
Pharmacokinetics
- Onset: 45-90 seconds (IV); 1-4 minutes (IO)
- Peak: 5-10 minutes (IO)
- Duration: 10-20 minutes (IV); 20 minutes (IO)
Adverse Effects
- Dizziness, lightheadedness, drowsiness, slurred speech
- Hypotension
- Muscle twitching
- Paresthesia (particularly in fingers or lips)
- Tinnitus
- Nausea or vomiting
- Cardiac arrhythmias
Overdose
Care for lidocaine overdose is primarily supportive, although some hospital therapies are available.
Drug Interactions
The risk of lidocaine toxicity is increased in patients taking cimetidine, ranitidine, or beta blockers. Lidocaine use in patients taking disopyramide may precipitate bradycardia that can progress to cardiac arrest.