hematoma blocks are effective pain management modalities for closed reduction of distal radius fractures . complications of hematoma blocks are associated with systemic reaction to anesthetic used .
we present a case report of an elderly patient who received a hematoma block of lidocaine and bupivacaine for a distal radius fracture and subsequently developed a generalized tonic clonic seizure .
we conclude that hematoma blocks with a combination of anesthetics may decrease the threshold to neurologic complications , especially in elderly patients .
hematoma blocks have long been used as analgesia for reduction of displaced fractures [ 1 - 4 ] . compared to procedural sedation
, there are fewer side effects with hematoma blocks than with other modes of analgesia . however , hematoma blocks are not without risks .
those risks include compartment syndrome , intravascular infiltration , as well as anesthetic related cardiac and neurologic side effects .
we present a case report of an elderly patient with a dorsal bending distal radius fracture who received a lidocaine and bupivacaine hematoma block . within seconds
we conclude by examining the relationship between lidocaine and bupivacaine and whether a synergic effect exists such that the threshold for neurologic complication is decreased when both drugs are used .
an 88 year old 63 kg woman , presented to the university of arizona medical center after she tripped and fell at her home . she complained of left hip and wrist pain .
physical examination revealed tenderness on palpation of the left hip with deformity and tenderness over the ipsilateral wrist .
radiographs confirmed a nondisplaced left intertrochanteric femur fracture and an ipsilateral dorsal bending distal radius fracture .
informed consent regarding closed reduction and splinting of the distal radius fracture were discussed with patient and family , all consenting .
the 22 gauge needle was inserted dorsally 3 cm proximal to fracture site , at a 30 degree angle .
over a thirty second interval , a 20 ml mixture of lidocaine 1% and bupivacaine 0.25% was infiltrated into the fracture hematoma . neither anesthetic contained epinephrine . within 15 seconds following the completion of injection ,
she developed mild tonic clonic movements of her upper and lower extremities lasting 15 seconds .
approximately one minute after completion of injection , patient began responding verbally . at approximately 5 minutes post injection , patient was awake , alert , and oriented .
she underwent closed reduction of her distal radius fracture and a sugar tong splint was applied .
she was admitted to the medicine service , underwent cephalomedullary nail fixation of her femur the following day , and was discharged from the hospital to inpatient rehabilitation on hospital day 4 . upon 2 and 6 week
fracture hematoma blocks are a proven , effective method of reducing pain and facilitating fracture reductions .
its use is a basic tool in the arsenal of any physician performing fracture reduction .
lidocaine and bupivacaine are frequently used in combination to rapidly achieve a long lasting anesthetic state .
the maximum recommended dose of lidocaine without epinephrine for a hematoma block is 4.5 mg per kg body weight .
the patient was injected 10 ml of 1% lidocaine , containing 100 mg of lidocaine , nearly one third the maximum lidocaine dose .
comparison of local anesthetic patient received to published maximum recommended dose . the maximum recommended dose of bupivacaine without epinephrine is 2 mg per kg body weight .
the patient was injected with 10 ml of 0.25% bupivacaine , containing 25 mg of bupivacaine , approximately one fifth the maximum bupivacaine dose .
local anesthetics , such as lidocaine and bupivacaine , inhibit the propagation and conduction of action potentials responsible for the transmission of neuronal impulses by reversibly blocking sodium channels of the nerve fibers .
local anesthetics are highly lipid soluble ; therefore , readily cross cell membranes and the blood brain barrier . both bupivacaine and lidocaine are thought to cause cns toxicity by blocking cerebral cortical inhibitory pathways in the amygdala causing unopposed excitatory activity that leads to seizures .
co - administration of bupivacaine and lidocaine has been shown to decrease the amount of bupivacaine required to induce seizures in a porcine model . in this study , 12 piglets were anesthetized and then randomly assigned to receive either bupivacaine alone at a rate of 1 mg / kg / min or bupivacaine and lidocaine , both running at a rate of 1 mg / kg / min .
the lidocaine plus bupivacaine group also received a 1 mg / kg bolus of lidocaine prior to the initiation of the infusion . in this study ,
the average bupivacaine dose required to induce seizure was lower in the group receiving the combination of bupivacaine and lidocaine , suggesting additive effect .
in addition , co - administration of bupivacaine and lidocaine has shown to increase the serum concentration of bupivacaine , possibly due to competition for protein binding sites .
bupivacaine has a smaller therapeutic window than lidocaine due to its higher potency , and increased serum levels may increase its potential for causing toxic effects .
the boston collaborative drug surveillance program found the overall incidence of seizures with intravenous lidocaine use was 5.7 cases per 1000 patients .
several risk factors for lidocaine toxicity were identified , including advanced age and prolonged hospitalization .
changes in muscle mass and lipid distribution in elderly patients may explain the alterations in the distribution of local anesthetics , which may play a role in the increased incidence of adverse events in this patient population .
the initial treatment of systemic toxicity due to local anesthetics is to discontinue the agent at the first sign of toxicity .
early signs of systemic toxicity include visual disturbances , declining mental status , tinnitus , and tongue numbness .
seizures associated with local anesthetic toxicity are typically self - limiting , but should be treated promptly to avoid potentially dangerous sequelae , such as hypoxia and acidosis .
benzodiazapines , barbiturates , and propofol have all been used successfully to terminate seizures due to local anesthetic toxicity . to our knowledge , this is the first case report of a patient experiencing a seizure after receiving a hematoma block with a combination of bupivacaine and lidocaine dosed well within the accepted dosing guidelines .
another case report exists describing cns toxicity in an elderly patient after receiving a hematoma block with lidocaine dosed at 5 mg / kg .
the study s authors recommend repositioning the needle into different areas of the hematoma while injecting small amounts of lidocaine into each site in order to minimize the potential for inadvertent intravascular administration .
we present a case of an 88 year old female with a dorsal bending distal radius fracture who developed a brief seizure and altered mental status after a fracture hematoma block .
nevertheless , given both the lidocaine and bupivacaine were well within their respective maximal dose limit , we caution against the use of multiple anesthetics , as they may lower the threshold for neurologic complications in a synergistic manner , especially in elderly individuals .
these episodes might be self limiting as in our case but treatment measures have to be kept ready when this procedure in undertaken although the vast majority of hematoma blocks provide excellent analgesic effect for basic orthopedic procedures , caution should be shown when lidocaine and bupivacaine are combined .
episodes of seizure might be self limiting but precautions need to be taken bobby dezfuli ( bd ) was the treating resident and gregory desilva ( gd ) was attending orthopaedic surgeon involved .
this was the first time bd & gd had a patient convulsing after hematoma block and this was quite unexpected .
chris edwards ( ce ) was involved to provide expert opinion on the role of lidocaine and bupavacaine .
the authors concluded that convulsions might be due to use of combination of local anaesthetic and possibly due to intravascular leakage of the drugs .
literature review helped authors to get clarity about mechanism of action of combination of anaethetics in causing seizures and possible prevention strategy .
 introduction : hematoma blocks are effective pain management modalities for closed reduction of distal radius fractures 
 . complications of hematoma blocks are associated with systemic reaction to anesthetic used.case report : we present a case report of an elderly patient who received a hematoma block of lidocaine and bupivacaine for a distal radius fracture and subsequently developed a generalized tonic clonic seizure . 
 the dose of both lidocaine and bupivacaine were well within the suggested dose limit . 
 the episode was self limiting and patient had the cast applied.conclusions:we conclude that hematoma blocks with a combination of anesthetics may decrease the threshold to neurologic complications , especially in elderly patients . precautions and ready treatment measures should be made available while performing closed reduction 
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