SHM Converge Scientific Abstract ePoster Gallery-Microneedling Mishap: Takotsubo Cardiomyopathy Induced by Topical Lidocaine Overdose

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This case describes a 78-year-old woman who developed acute respiratory distress, hypotension, flushing, and facial/orolabial edema about 30 minutes after receiving compounded topical lidocaine before an outpatient microneedling procedure. Initial concerns included anaphylaxis, lidocaine overdose, and local anesthetic systemic toxicity (LAST). Workup showed lactic acidosis, troponin elevation, mild transaminitis, and no ischemic ECG changes; tryptase was normal, making allergy less likely. Toxicology determined the product contained a very high lidocaine concentration (30% total anesthetic mixture, including 23% lidocaine), far above the recommended maximum topical lidocaine concentration of 4%.<br /><br />Her presentation was most consistent with topical lidocaine overdose rather than classic LAST because she did not develop seizures or dysrhythmias. During hospitalization, imaging showed diffuse pulmonary edema on chest x-ray and takotsubo cardiomyopathy on transthoracic echocardiogram with global left ventricular hypokinesis and apical ballooning. Despite the severity of presentation, her vitals and lab abnormalities stabilized quickly with supportive care, and serial ECGs remained free of ischemia or arrhythmias. She was discharged with instructions to avoid unnecessary or elective exposure to topical lidocaine and to ensure future topical formulations do not exceed 4%. Follow-up echocardiography later showed recovery of ejection fraction to 55% with normal biventricular function.<br /><br />The case highlights that lidocaine overdose and LAST, though uncommon, can be life-threatening even with topical use. Clinicians should maintain awareness of toxicity risk, especially with compounded products and outpatient dermatologic procedures, and provide patient counseling about safe dosing and monitoring.

Asset Subtitle

Caroline Horne

Meta Tag

Author List Caroline Horne, Natalie Reed, Yaffa Ali

Category Clinical Vignettes

Concept Lidocaine Overdose

Concept Local Anesthetic Systemic Toxicity

Concept Allergic Reaction

Concept Lidocaine

Concept Topical Anesthetic Exposure

Distinguished Non-Finalist

Presenter Organization Atrium Health Carolinas Medical Center

Presenting Author Caroline Horne

Track Adult

Keywords

topical lidocaine overdose

local anesthetic systemic toxicity

LAST

anaphylaxis differential

compounded anesthetic

microneedling procedure

takotsubo cardiomyopathy

pulmonary edema

lidocaine toxicity

patient counseling

Lidocaine Overdose

Local Anesthetic Systemic Toxicity

Allergic Reaction

Lidocaine

Topical Anesthetic Exposure