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Clin Exp Emerg Med 2016;3(2):105-108
http://dx.doi.org/10.15441/ceem.15.103
Intravenous lidocaine for the treatment eISSN: 2383-4625
of acute pain in the emergency
department
Brendan Michael Fitzpatrick, Michael Eugene Mullins
Division of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
Received: 2 January 2016 Revised: 5 February 2016 Objective To evaluate intravenous lidocaine's safety and efficacy as an analgesic agent in the
Accepted: 6 February 2016 treatment of a variety of painful conditions presenting to the emergency department.
Correspondence to: Methods This case series identified seventeen patients who received lidocaine over a six month
Brendan Michael Fitzpatrick period and recorded demographic data, amount of lidocaine administered, the amount of opioid Division of Emergency Medicine, medication administered before and after lidocaine, pre- and post-lidocaine pain scores, and any Washington University School of qualitative descriptors of the patient's pain recorded in the record. Side effects and adverse events Medicine in St. Louis, 660 E. Euclid Ave, were also recorded.
CB 8072, St. Louis, MO 63110, USAE-mail: [email protected] Results Of the seven patients who had a pre- and post-lidocaine pain score recorded, the mean
reduction was 3 points on a 10 point scale. Patients who received lidocaine used less opioid med-
ication. One patient received an improperly high dose of lidocaine and suffered a brief seizure
and cardiac arrest, but was quickly resuscitated.
Conclusion This series suggests that lidocaine may be a useful adjunct in the treatment of acute-
ly painful conditions in the emergency department.
Keywords Lidocaine; Analgesia; Pain control
What is already known
Intravenous lidocaine has been used to treat pain in postoperative patients,
opioid-refractory chronic pain, and oncologic pain. Recent data suggests intra-
venous lidocaine may also be beneficial in treating acutely painful conditions in
the emergency department.
What is new in the current study
This case series reviewed intravenous lidocaine's effectiveness and safety in
How to cite this article: treating a variety of painful conditions in the emergency department, including Fitzpatrick BM, Mullins ME. Intravenous but not limited to acute fracture pain, abdominal pain, sickle cell pain crisis, lidocaine for the treatment of acute pain in the emergency department. Clin Exp Emerg burns, contusions, and penetrating trauma. Lidocaine seemed to reduce pain and decreased the amount of opioids required after its administration. When used in appropriate doses, there were no significant side effects. This case series adds to the body of literature suggesting that intravenous lidocaine might be This is an Open Access article distributed considered as an adjunct to acute pain management in the emergency depart- under the terms of the Creative Commons ment across a spectrum of painful conditions. Copyright 2016 The Korean Society of Emergency Medicine
IV lidocaine for the treatment of acute pain in the ED ischemic foot, herpes gingostomatitis, foot contusion after motor vehicle collision, grease burn, and a gunshot wound to the hand. Emergency physicians are familiar with lidocaine's use as a local Ten of the patients were admitted, six were discharged home, and anesthetic. For many years, lidocaine was also part of the advanc- the patient with the ischemic foot underwent emergency surgery.
ed cardiac life support algorithm as an anti-arrhythmic,1 and is The mean dose of total lidocaine was 148.53 mg, with a medi- even still recommended in some airway texts as a neuroprotec- an and mode of 100, and range of 75 to 400 mg. Six of the sev- tive agent used prior to airway management in patients with ele- enteen patients received two doses of lidocaine, and the other vated intracranial pressure.2 eleven received only one dose. Only seven patients had a pain However, lidocaine's use as an intravenous analgesic has been score recorded before and after the administration of lidocaine. far less popular in emergency medicine than in other areas of med- Two of these seven rated their pain as a 9/10, and five rated their icine. Intravenous lidocaine has been used for decades in treating pain as a 10/10 prior to the administration of lidocaine. The aver- oncologic pain,3 post-surgical pain management,4 and in chronic age pain reduction was 3 in these seven patients. One patient re- opioid-refractory pain.5 More recently, trials have shown analge- ported no change in their 10/10 pain, and another noted an im- sic efficacy in the treatment of painful conditions in the emer- provement from 10 to 5. gency department; particularly in the treatment of renal colic6,7 Reviewing nursing and provider descriptors of pain, several had and limb ischemia.8 patient quotations that indicated some improvement in their pain. The objectives of this case series were to evaluate intravenous Two patients were quoted as saying their pain was "better", an- lidocaine's safety and efficacy as an analgesic agent in the treat- other the pain was "easing up", and one patient was quoted as ment of a variety of acutely painful conditions presenting to a ter- saying "I feel fine". Providers used the terms "improvement", "much tiary urban academic emergency department.
better", and "better". Two patients described their pain as aching both before and after lidocaine, but there was nothing recorded about the pain's intensity. Three patients were documented as sleeping after receiving lidocaine.
Patients who received intravenous lidocaine for acute pain during The patients who received intravenous lidocaine received a to- a six month period from 1 January 2012 through 1 July 2012 were tal of 19.07 mg of morphine-equivalent opioids. The mean total eligible for inclusion in this series. We excluded patients who re- amount of opioid received prior to lidocaine was 11.1 and 8.5 mg ceived intravenous lidocaine for other reasons, e.g. arrhythmia, after lidocaine. neuroprotection for intubation. We identified eligible patients by One patient suffered a serious adverse effect from intravenous reviewing the institution's pharmacy data during this time. The lidocaine. The treating physician mistakenly free-text ordered li- study was approved by the institutional review board. docaine 100 mg and mistakenly approved when the nurse pre- Data recorded included the patient's age, sex, chief complaint sented 100 mL of 1% lidocaine, which was 5 vials of 20 mL 1% and/or diagnosis, disposition, total amount of intravenous lido- lidocaine. At the end of the second vial, which was a cumulative caine received in milligrams, triage pain score, post-lidocaine pain dose of 400 mg of lidocaine, the patient seized. He soon became score, and any qualitative descriptors used by the patients to de- bradycardic, and eventually had a brief cardiac arrest. He was re- scribe their pain before and after lidocaine. Additionally, the amo- suscitated successfully and made a full neurologic recovery. The unt of opioids administered before and after initial lidocaine in dose of 400 mg is four times greater than the next largest single morphine equivalents, and any recorded side effects or adverse dose given, 100 mg, and exceeds the usual studied dose. Root cause events from lidocaine were also documented.
analysis determined that the physician was unfamiliar with the correct dosing of lidocaine. Seventeen patients met the inclusion criteria. Seven women and ten men comprised the study group, with a median age of 48 years Intravenous lidocaine has shown promise in treating acutely pain- and an age range of 23 to 81 years. The most common diagnosis ful conditions, and in others it has shown no benefit. The purpose and cause of pain was an acute fracture in 5 patients, followed of this case series was to generate hypotheses for future areas of by sickle cell pain crisis, acute back pain, and abdominal pain, with investigation. During a six-month-period, patients with fractures, 2 patients each. Other diagnoses were trigeminal neuralgia, acute sickle cell vasoocclusive crises, abdominal pain, neuropathic pain, www.ceemjournal.org Brendan Michael Fitzpatrick, et al.
and even mucocutaneous ulcers were treated with intravenous and completeness of the written record. In a busy urban emer- lidocaine. The results suggest that some patients experienced less gency department, physician and nursing charting may not accu- pain after administration of this agent. rately reflect the clinical reality. For instance, only 7 of the 17 pa- Lidocaine is an aminoethylamide that acts primarily as a sodi- tients had a pain score recorded both before and after the admin- um channel inhibitor, and exerts its effects as a local anesthetic istration of lidocaine. by blocking sodium influx and halting action potential conduc- This type of review is also unable to control for bias and con- tion. It blocks both open and inactivated sodium channels, with a founders, as there was no blinding of the patient, physician, or greater effect seen at the already depolarized channels secondary nurses. Cause and effect are also nearly impossible to establish, to a greater positive resting potential. Thus, nerves that are re- as the majority of patients received morphine prior to lidocaine, petitively stimulated such as those that are ischemic are more and improvement in their pain may have been due to the opioids, affected by lidocaine than non-stimulated nerves.9 Locally, this or at least a synergistic effect with the lidocaine. block occurs at the Aβ, Aδ, or C primary afferent nerves, and at This case series adds to the small but growing body of litera- high enough concentration, causes a complete neural blockade in ture that supports lidocaine's judicious use as part of a multi-mod- both injured and uninjured nerves. Systemic lidocaine, however, al analgesia approach to acute pain in the emergency department. does not completely block conduction of these fibers if they are Future studies should continue to evaluate intravenous lidocaine's healthy. Instead, its effects occur primarily at acutely injured nerves role in treating a variety of painful conditions in the emergency that have a tonic action potential discharge.10 A similar effect oc- setting. Acute fracture pain is one area in which lidocaine may be curs in animal models at damaged dorsal root basal ganglia, in of benefit, as there is an acute injury that may be susceptible to which systemic lidocaine reduced sympathetic noradrenergic spro- its sodium blockade of injured tissue.
uting. This benefit lasted for 7 days after the cessation of lido-caine.11 CONFLICT OF INTEREST
In the emergency setting, Soleimanpour et al.6 conducted an open label case series of patients treated with lidocaine 1 mg/kg No potential conflict of interest relevant to this article was re- for relief of renal colic. Based upon favorable results, they con- ducted a randomized trial comparing lidocaine 1 mg/kg to mor-phine 0.1 mg/kg for relief of renal colic and found that lidocaine achieve better pain reduction in the first two hours after drug administration.7 Intravenous lidocaine has shown efficacy in treat- 1. Guidelines 2000 for Cardiopulmonary Resuscitation and Emer- ing limb ischemia,8 neuropathic pain, postoperative abdominal gency Cardiovascular Care. Part 6: advanced cardiovascular pain, and headache.12 However, it had no benefit in treating burns life support: section 5: pharmacology I: agents for arrhyth- and radicular back pain.13,14 It would seem, then, that the role of mias. The American Heart Association in collaboration with intravenous lidocaine in the treatment of acute pain is unclear. the International Liaison Committee on Resuscitation. Circu- This case series reviewed the use of intravenous lidocaine for a lation 2000;102(8 Suppl):I112-28.
variety of painful complaints, with varying success. Some patients 2. Salhi B, Stettner E. In defense of the use of lidocaine in rapid reported significant decreased levels of pain and reduced admin- sequence intubation. Ann Emerg Med 2007;49:84-6. istration of opioids. Lidocaine, when administered at doses up to 3. Sharma S, Rajagopal MR, Palat G, Singh C, Haji AG, Jain D. A 3 mg/kg, was well-tolerated by patients. The single significant phase II pilot study to evaluate use of intravenous lidocaine adverse event occurred at a dose of 3.66 mg/kg, and like any med- for opioid-refractory pain in cancer patients. J Pain Symptom ication, care must be taken to educate physicians and nurses re- garding the appropriate dosing. 4. De Oliveira GS Jr, Fitzgerald P, Streicher LF, Marcus RJ, McCar- It may be that lidocaine will be found to be a useful adjunct in thy RJ. Systemic lidocaine to improve postoperative quality of some conditions, and not useful in others. Similarly, it remains to recovery after ambulatory laparoscopic surgery. Anesth Analg be seen what lidocaine's effect is when combined with other an- algesics such as opioids and non-steroidal anti-inflammatory agents. 5. Thomas J, Kronenberg R, Cox MC, Naco GC, Wallace M, von This series does suggest that some patients with acutely painful Gunten CF. Intravenous lidocaine relieves severe pain: results conditions may benefit from intravenous lidocaine. of an inpatient hospice chart review. J Palliat Med 2004;7: Limitations of this case series includes reliance on the accuracy Clin Exp Emerg Med 2016;3(2):105-108 IV lidocaine for the treatment of acute pain in the ED 6. Soleimanpour H, Hassanzadeh K, Mohammadi DA, Vaezi H, lized treatment for pain? J Palliat Med 2007;10:798-805.
Esfanjani RM. Parenteral lidocaine for treatment of intracta- 11. Devor M, Wall PD, Catalan N. Systemic lidocaine silences ec- ble renal colic: a case series. J Med Case Rep 2011;5:256.
topic neuroma and DRG discharge without blocking nerve 7. Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfan- conduction. Pain 1992;48:261-8.
jani RM, Soleimanpour M. Effectiveness of intravenous lido- 12. Rosen N, Marmura M, Abbas M, Silberstein S. Intravenous li- caine versus intravenous morphine for patients with renal colic docaine in the treatment of refractory headache: a retrospec- in the emergency department. BMC Urol 2012;12:13. tive case series. Headache 2009;49:286-91. 8. Vahidi E, Shakoor D, Aghaie Meybodi M, Saeedi M. Compari- 13. Wasiak J, Spinks A, Costello V, et al. Adjuvant use of intrave- son of intravenous lidocaine versus morphine in alleviating nous lidocaine for procedural burn pain relief: a randomized pain in patients with critical limb ischaemia. Emerg Med J double-blind, placebo-controlled, cross-over trial. Burns 2011; 9. Roden DM. Antiarrhythmic drugs. In: Limbird LE, Gilman AG, 14. Tanen DA, Shimada M, Danish DC, Dos Santos F, Makela M, editors. Goodman & Gilman's the pharmacological basis of Riffenburgh RH. Intravenous lidocaine for the emergency de- therapeutics. 10th ed. New York: McGraw-Hill; 2001. p. 961-2.
partment treatment of acute radicular low back pain, a ran- 10. McCleane G. Intravenous lidocaine: an outdated or underuti- domized controlled trial. J Emerg Med 2014;47:119-24.
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