LipidRescue™ Resuscitation

On 1/20/11 a 6 month old 9kg infant male, with a history of full term gestation, previously well, was brought in to the emergency department by his parents for ingrown toenails bilaterally on both great toes. At aproximately 19:00, the physician assistant caring for the pt injected 1.5ml of lidocaine 2% without epinepherine to digital block each great toe. Total lidocaine dose given to the pt was 6.7mg/kg. Toxic dose of lidocaine is >4.5mg/kg.

At 19:50 the pt began having an acute continuous generalized tonic clonic seizure.
The pt's vital signs at the onset of seizure activity was Temp 97.9 HR 177 BP 94/71 RR 38

Despite 3 subsequent ativan 0.7mg IVP infusions, generalized seizure activity persisted.

Two Intalipid 20% bolus infusions of 1.5ml/kg were given at 20:13 1nd 20:16 followed by a 60 minute continuous infusion of 0.25ml/kg/min seen without change in the pt's seizure activity.

A Phenobarbital 20mg/kg loading dose was started at 20:25.

The pt stopped seizing at 21:09 and remained seizure free until transfer to a pediatric inpatient ICU at 23:56.

The pt remained hemodynamically stable throughout his entire stay in the emergency department without any hypotensive episodes and continued in sinus rhythm with heart rates between 122-200.

In this case, for a neurolgic complication of lidocaine overdose, lipid emulsion therapy did not seem to provide obvious benefit. Conversely lipid emulsion infusion did not appear to have any adverse effects.

It appears by your description that there was a cause and effect relationship with the digit block and the seizure activity. Was the local anesthetic confirmed? Possible drug error? Have to wonder why the PA chose 2% Lidocaine instead of 1% in this case. As for why there was no response with the intra lipid treatment achieving the desired response.... interesting??? Thanks for the Post, quite thought provoking.