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Lidocaine may be considered a suitable antiarrhythmic that can be used to treat cardiac arrest from VT/VF.
Lidocaine is now included in the AHA Cardiac Arrest diagram along with amdidoarne. Emphasis should not be on the use of medications and it is the AHA recommendation to place more emphasis on high quality CPR and early defibrillation.
Lidocaine indications for ACLS
- In ACLS, Lidocaine is used intravenously for the treatment of ventricular arrhythmias. (VT/VF)
- It is also useful for the treatment of stable monomorphic VT with preserved ventricular function and for stable polymorphic VT with preserved left ventricular function, normal QT interval, and correction of any electrolyte imbalances.
The overall benefits of lidocaine for the treatment arrhythmias in cardiac arrest has come under scrutiny. It has been shown to have no short term or long term efficacy in cardiac arrest.
Routine prophylactic use is contraindicated for acute myocardial infarction.
Side Effects
Lidocaine should be used with caution due to negative cardiovascular effects which include hypotension, bradycardia, arrhythmias, and/or cardiac arrest. Some of these side effects may be due to hypoxemia secondary to respiratory depression.
Lidocaine Toxicity
Symptoms of lidocaine toxicity progress in the following predictable pattern. It begins with numbness of the tongue, lightheadedness, and visual disturbances and progresses to muscle twitching, unconsciousness, and seizures, then coma, respiratory arrest, and cardiovascular depression.
There are several conditions that increase the potential for lidocaine toxicity:
- Liver dysfunction increases the risk of toxicity due to lidocaine being metabolized by the liver.
- Low protein increases the risk of toxicity because lidocaine is protein bound.
- Acidosis can also increase the risk of toxicity since acidosis increase the potential of lidocaine to dissociate from plasma proteins.
Dosing
Cardiac Arrest from VT/VF:
- Initial dose: 1 to 1.5 mg/kg IV/IO
- For refractory VF may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; maximum 3 doses or total of 3mg/kg
Perfusing Arrhythmia:
For stable VT, wide-complex tachycardia of uncertain type and significant ectopy:
- Doses Range from 0.5 to 0.75 mg/kg and up to 1 to 1.5mg/kg
- Repeat 0.5 to 0.75 mg/kg every 5-10 minutes with maximum total dose of 3 mg/kg
Maintenance infusion:
- 1 to 4 mg/min (30-50 mcg/kg/min)
Discontinue a lidocaine infusion immediately if signs of toxicity develop.
B says
For stable VT, wide-complex tachycardia of uncertain type and significant ectopy:
In the above case, is the lidocaine also given as a push dose?
ACLS says
Lidocaine would not typically be given for the situation you are describing.
IV push lidocaine is typically used in certain situations, such as cardiac arrest or unstable tachycardia. Lidocaine may be administered as a rapid intravenous push to achieve a therapeutic effect quickly.
The most common treatment for stable, wide-complex tachycardia of uncertain type and significant ectopy is elective synchronized electrical cardioversion.
Kind regards,
Jeff
Colby says
Do you hang lidocaine after ROSC the same as you hang amiodarone if you convert with lido?
ACLS says
That is correct. However, you would only hang amiodarone or lidocaine if there was continued anti-rhythmic activity during the post-arrest phase. According to the American Heart Association, antiarrhythmics would be used during the post-cardiac arrest phase only if arrhythmias persist.
If arrhythmias do persist then the antiarrhythmic that was used to achieve ROSC would be utilized.
Kind regards,
Jeff
Peter J says
What is the recommended dose of lidocaine for the purpose of pain of an IO insertion?
ACLS says
It’s the same as the dosing for intravenous.
Kind regards,
Jeff
jeffrey kasbohm says
i suspect you mean for localized pain from placing an IO needle / catheter. Usually (in my experience you’re not going for the IO access unless all other IV access points are inaccessible and patient is crashing — in a word patient isn’t going to feel it) but in a really hypotensive person and if you have time, I don’t see local injection affecting total (systemic) dosing that much. And what I’ve heard from military paramedics who train on each other it’s not as painful as you’d think — that is placing the IO needle. They’re tougher than I am 🙂 .
Hill says
What size NS bag would you dilute Lidocaine 100mg/5 mL into? And how much mg/mL would need to be diluted to reach appropriate maintenance drip?
For example if I use a 1000mL NS bag how much mg of lidocaine would need to be diluted into bag?
ACLS says
An IV infusion of lidocaine by adding 1g of lidocaine (using 25 ml of a commercially available 4% or 5 ml of a 20% injection) to 1 L of D5W injection to provide a concentration of 1 mg/ml.
Kind regards, Jeff
Ahmad says
When would you give Lidocaine in refractory Vfib after giving multiple defibrillations and 2 doses of Amiodarone (300mg and 150mg)?
ACLS says
lidocaine may be given at any time after the two doses of amiodarone. It just needs to be given at the beginning of a cycle of CPR in order to ensure good distribution within the central circulation.
Kind regards,
Jeff
Thaimu Kargbo says
Can inj lidocaine use in cardiac arrhythmias?
ACLS says
Yes, lidocaine can be used for the treatment of cardiac arrhythmias. It is an alternative to amiodarone.
Kind regards,
Jeff
Andy says
How is lidocaine dosing measured? By ideal, actual, or total body weight?
ACLS says
Ideally, you would use actual body weight. However, in emergencies, the weight is not always known. I have see estimated weights or weights reported by family used.
Kind regards,
Jeff
Jennifer Wolcott says
I had a student ask why the second dose of lidocaine for refractory VF was lower. Is this due to concerns for toxicity?
Jeff with admin. says
Amiodarone is the primary medication that is used for refractory ventricular fibrillation. The lower second dose is due to the long half-life of amiodarone and the risk for toxicity if ROSC occurs.
The same is true for lidocaine even though the half life is much shorter than amiodarone.
Kind regards,
Jeff
Christine says
can lidocaine be used to treat a pt who is crashing. Brady and hypotensive? Only access is an IO.
Jeff with admin. says
I have never heard of any person being treated for bradycardia using lidocaine. Lidocaine is an antiarrhythmic and would not be indicated for bradycardia.
The correct treatment for hypertensive bradycardia would be to initiate transcutaneous pacing as soon as possible and possibly utilize atropine while waiting for transcutaneous pacing.
Also, according to AHA protocol an intravenous infusion of epinephrine or dopamine could be used for the treatment for hypotension and bradycardia.
Kind regards,
Jeff
Chase says
I just had a provider want me to spike a lidocaine drip on a patient with multiple PVCs. The patient was asymptomatic despite shortness of air related to abdominal bloating. I was concerned because if the patient decompensated into VT, lidocaine is not first treatment. Why would the provider have wanted lidocaine instead?
Jeff with admin. says
There would be no indication for lidocaine drip in this case. I haven’t seen someone start a lidocaine drip it years. There is no research that I know of that supports the use of a lidocaine drip to suppress asymptomatic PVCs.
Kind regards, Jeff
Brian says
Treat the Rate, before the Rhythm. Symptomatic Unstable Bradycardia should be paced regardless of the rhythm
Curt says
Chris, Bob’s question is a little outside the scope of cardiac arrests where the data the ACLS guidelines come from. He appears to be concerned with a patient with frequent PVCs (perhaps multiple short runs of VT) with signs and symptoms that suggest decompensation. While amiodarone can suppress these, a number of other agents may be valuable. Your suggestion to involve a cardiologist or electrophysiologist is a good one.
Bob says
Dinosaur EMT-P here. Confusing old algorithms with new is always a huge fear. Then the terminology changes too. “Monomorphic Wide VT” (PVCs?) I was looking for information regarding Lidocaine VS Amioderone in the case of decompensated PVCs > than 6-min. I couldn’t find ANYTHING referencing PVCs. Used to be a cardinal rule, an absolute thing. I understand all the good things about Amioderon and I certainly understand and practice the theory that PVCs are typically a result of poor oxygenation, improve the oxygenation typically the PVCs will sort themselves out. Please bring me out of the stone age…
Chris with admin. says
I’ve never heard of decompensated PVCs. I’m not sure I really understand the question. PVCs are not treated with medication via the ACLS Algorithms. Amiodarone is the first drug of choice for V-Tach simply because it’s the only drug that has been validated with research. If someone is having recurring PVCs and have never seen a cardiologist, they should see a cardiologist.
Kind regards,
Chris
Willy Lauder says
For the most part, we are no longer too concerned with PVC’s, so long as they are perfusing. Even then, there are lots of reasons PVC’s happen so taking them away is high on the priority list. Finding out why they occur is the treatment. Sometimes taking them away causes more problems later.
Sandeep says
If there is shortage of Lidocaine 2% hcl injections that are specifically marked for cardiac arrhythmia can we use the Single dose 2% (20mg/ml) 10mL Vial NDC 0409-4282-02 for cardiac arrhythmia.
Thank you
Greg says
Why would lidocaine be appropriate for ventricular tachyarrhythmias? As a sodium channel blocker (Ib) it shortens the ERP, wouldn’t that be counter-intuitive to treating a tachycardia?
Gio says
I’m confused if how many ml of NS should we dilute to 100mg Lidocaine for IVP.Thanks
Jeff with admin. says
Dilute to 100mg/5ml. Kind regards, Jeff
Eric says
in cath lab setting on a STEMI, pt in VF/VT is it suitable to push a whole amp of lido?
Cath lab RN
Jeff with admin. says
It depends on the dose. The typical dosage for the treatment of VF or pulseless VT is 1 to 1.5 mg/kg. You would have to know how much was in the dose that was given. Kind regards, Jeff
k.h says
Is it mandatory lidocaine premixed bag to be available in crash cart
Jeff with admin. says
No. Lidocaine is not mandatory on a crash cart. It would be wise to have it available but it is not mandatory. It would be wise to stock some type of antiarrhythmic and if not amiodarone then lidocaine would be a good second choice.
Keep in mind, hospitals set their own policies for what should go on a crash cart. You need to check with your facility to see what is “mandatory” on their crash carts. They can set the policy.
Kind regards,
Jeff
Rajkumar says
Is there any duration to administer lidocaine injection like a slow iv or fast iv
ACLS says
When lidocaine is used during cardiac arrest, boluses should be administered rapid IV push and followed by 20 mL of normal saline.
Kind regards,
Jeff