Pharm

Lidocaine

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Lidocaine

  • Indications
  1. Amiodarone has replaced Lidocaine as first line agent in ACLS and PALS protocols
    1. However Lidocaine may have higher rate of ROSC and lower morbidity and mortality than Amiodarone
    2. Wagner (2023) Chest 163(5):1109-1119 +PMID: 36332663 [PubMed]
  2. Ventricular Fibrillation
  3. Ventricular Tachycardia (Wide Complex Tachycardia)
    1. Use Lidocaine only if unknown etiology
    2. Not indicated for drug induced Arrhythmia
    3. Not indicated for metabolic induced Arrhythmia
  4. Post-Resuscitation for ventricular Arrhythmia
    1. Myocarditis
    2. Structural heart disease
  • Contraindications
  1. Wide-complex ventricular escape rhythm
  2. Associated with Bradycardia
  • Mechanism
  1. See Lidocaine Local Skin Anesthesia
  2. Class Ib Antiarrhythmic Drug
  3. Increases conduction velocity in the AV Node, His Bundle and Purkinje Fibers
    1. Shortens QT Interval
  4. Suppresses ventricular Arrhythmias
    1. Terminates reentrant ventricular Arrhythmia
    2. Increases Ventricular Fibrillation threshold
      1. Requires high plasma Lidocaine levels (e.g. 6 mcg/ml)
  5. Suppresses ventricular ectopy (decreases automaticity)
    1. Post Myocardial Infarction, routine prophylactic Lidocaine use not recommended
  • Dosing
  • Pediatric
  1. Dose: 1 mg/kg IV/IO every 10 to 15 min up to 3 to 5 mg/kg in 1 hour
  2. ET Dose: Use 2 to 2.5 times the IV dose
  3. May continue with infusion dosing as below
  • Dosing
  • Adult
  1. Ventricular Fibrillation
    1. Dose: 1.0-1.5 mg/kg IV/IO push
    2. ET Dose: Use 2 to 2.5 times the IV dose in 10 ml Normal Saline
    3. May repeat in 3-5 min to max dose 3 mg/kg
    4. May continue with infusion dosing as below
  2. Ventricular Tachycardia (with a pulse)
    1. First: 1.0-1.5 mg/kg IV/IO push
    2. Next: 0.5-0.75 mg/kg IV/IO push every 5 to 10 minutes
    3. Maximum total, cumulative dose: 3 mg/kg
    4. May continue with infusion dosing as below
  • Dosing
  • Infusion (Pediatric and Adult)
  1. Preparation
    1. Lidocaine 4 g in 500 ml D5W (8 mg/ml)
    2. Precede infusion with 1 mg/kg bolus loading dose
    3. Then 20-50 mcg/kg/min up to 1 to 4 mg/min infusion
  2. If hepatic Blood Flow is compromised (e.g. CHF, liver disease, elderly)
    1. Decrease dose to under 20 mcg/kg/min
  • Adverse Effects
  1. Myocardial depression of conduction and contractility
    1. Concurrent Antiarrhythmic therapy
    2. Sick Sinus Syndrome
    3. Left Ventricular Dysfunction
  2. Circulatory depression
    1. May occur with rapid bolus dosing
  3. Neurologic changes (esp. with prolonged infusion)
    1. Drowsiness or Disorientation
    2. Decreased Hearing acuity
    3. Paresthesias
    4. Muscle Twitching (Fasciculations)
    5. Seizures (high dose)
  4. Overdosage
    1. Third degree AV Heart Block
    2. Altered AV conduction
    3. Sinus node automaticity depressed
  • Safety
  1. Unknown safety in Lactation
  2. Pregnancy Category B
  • Metabolism
  1. Rapid hepatic metabolism (to 2 active metabolites)
  2. Renal excretion
  • Drug Interactions
  1. Lidocaine serum levels increased by other medications
    1. Cimetidine
    2. Medications that reduce hepatic perfusion (e.g. Beta Blockers)
  • References
  1. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 74-5
  2. Hamilton (2020) Tarascon Pocket Pharmacopoeia
  3. Panchal (2018) Circulation 138(23):e740-e749 +PMID: 30571262 [PubMed]