Case Study of Fatal Stroke Following Intranasal Lidocaine

A 39-year-old man presented with new onset right hemiparesis and aphasia within an hour of using approximately 120 mL lidocaine 4% topical solution intranasally. Lidocaine had been prescribed over a 3-week period for pain due to multiple debridements of the nasal septum. A total of 650 mL of 4% lidocaine (26 g) had been dispensed to the patient during this time. The patient had a significant history of drug abuse, including snorting crushed tablets. Otherwise he was a healthy man with no chronic diseases or conditions. On arrival, and from previous exams, EKGs were normal without conduction delays. Electrolytes and CBC results were within normal range. The MRI/MRA showed a new thrombus with left middle cerebral artery distribution affecting one-third of the brain mass, including brain stem. Lidocaine likely contributed to cardiovascular embolic development, possibly from a sudden drop in blood pressure and known cardiovascular effects of sodium channel blockade. The patient expired from acute respiratory failure secondary to brainstem damage. Solutions of topical lidocaine should not be prescribed for use on open wounds or abraded skin as drug absorption will be increased, especially in highly vascularized nasal passages.