Clinical communicationLidocaine-induced altered mental status and seizure after hematoma block
Introduction
Fracture reduction in the Emergency Department (ED) can be a painful experience for patients. Multiple studies have demonstrated the efficacy of hematoma block in producing adequate anesthesia, enabling Colles’ fracture reduction (1, 2, 3, 4). Rare but potential complications from injection into the hematoma include compartment syndrome, infection, vascular infiltration, or local anesthetic toxicity (5). We present a case report of a patient who developed acute mental status changes and generalized seizure following the attempted administration of a lidocaine hematoma block. The rapid onset of seizure development following this injection was most likely due to inadvertent intravascular administration.
Section snippets
Case report
A 94-year-old 40-kg woman presented to the ED following a ground level fall after tripping. On presentation she complained only of left wrist pain. Her past medical history was significant for osteoporosis and peripheral vascular disease. She was taking no medications and had no known drug allergies. The patient lived alone and was self-sufficient. The physical examination was normal except for swelling and deformity of the left wrist. Radiographic evaluation revealed an ulnar styloid fracture
Discussion
The hematoma block has been in use for years to provide anesthesia for fracture reduction. The hematoma block for Colles’ fractures is performed by inserting a needle dorsally into the hematoma using sterile technique. Confirmation of entrance into the hematoma is determined by aspirating blood. The hematoma is then infiltrated slowly with either 1% or 2% plain lidocaine. Adequate anesthesia typically occurs within 5 min and the fracture may then be reduced.
It has been recommended by the
Conclusion
Although lidocaine-induced altered mental status and seizure activity has been described after topical, regional and local anesthesia, lidocaine toxicity following infiltration of a hematoma block has not been described (21, 22, 23). Our patient, an elderly woman, experienced generalized seizure activity after rapid hematoma block infusion of approximately 5 mg/kg of lidocaine. Following several simple guidelines potentially could have avoided this complication. First, the total dosage of
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2014, Handbook of Clinical NeurologyCitation Excerpt :Twitching can progress to partial or generalized seizures accompanied by respiratory depression (Meschia and Biller, 1998; Leary and Caplan, 2009). Seizures precipitated by lidocaine usually occur when plasma levels exceed 9 μg per mL (Meschia and Biller, 1998) and have been reported with topical, subcutaneous, and intravenous administration (Boston Collaborative Drug Surveillance Program, 1972; Pelter et al., 1989; Meschia and Biller, 1998; Dorf et al., 2006; Brown et al., 2009). The Boston Collaborative Drug Surveillance Program found a convulsion rate of 5.7 per 1000 patients treated with intravenous lidocaine for arrhythmias (Boston Collaborative Drug Surveillance Program, 1972; Meschia and Biller, 1998).
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Clinical Communications (Adults) is coordinated by Ron Walls, md, of Brigham and Women’s Hospital and Harvard University Medical School, Boston, Massachusetts