Is it safe to use lidocaine (lido) with epinephrine (epi) for a forehead laceration?

From the Guidelines

Yes, it is generally safe to use lidocaine with epinephrine for forehead lacerations. The traditional teaching to avoid epinephrine in "fingers, toes, nose, penis, and ears" due to concerns about tissue necrosis does not apply to the forehead. The forehead has excellent blood supply with multiple collateral vessels, making the risk of ischemia extremely low. Using lidocaine with epinephrine (typically 1% or 2% lidocaine with 1:100,000 epinephrine) provides several advantages: it prolongs the anesthetic effect, reduces bleeding at the wound site which improves visualization, and may reduce the total amount of lidocaine needed.

• The maximum safe dose is 7 mg/kg of lidocaine with epinephrine (compared to 4-5 mg/kg without epinephrine) 1.
• When injecting, use the smallest effective volume, inject slowly to minimize pain, and consider buffering with sodium bicarbonate (9:1 ratio of lidocaine to bicarbonate) to reduce injection discomfort.
• Allow 5-10 minutes after injection for the epinephrine to take full effect before beginning the repair. The addition of epinephrine to local anesthesia for dermatologic procedures has been shown to be safe and effective, with no increased risk of complications, as demonstrated in studies published in the Journal of the American Academy of Dermatology 1.
• The use of epinephrine in concentrations of 1:100,000 and 1:200,000 has been recommended for dermatologic surgery, as it provides effective vasoconstriction and prolongs the anesthetic duration of lidocaine and bupivacaine 1.
• The guidelines for the use of local anesthesia in office-based dermatologic surgery emphasize the importance of using the lowest effective concentration of epinephrine and calculating the maximum safe dose of lidocaine with epinephrine before administration 1.

From the FDA Drug Label

Local anesthetic solutions containing a vasoconstrictor should be used cautiously and in carefully circumscribed quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply. Use in the Head and Neck Area Small doses of local anesthetics injected into the head and neck area, including retrobulbar, dental and stellate ganglion blocks, may produce adverse reactions similar to systemic toxicity seen with unintentional intravascular injections of larger doses

The use of lidocaine with epinephrine (lido-epi) for a forehead laceration is not recommended due to the risk of ischemic injury or necrosis in areas with compromised blood supply, such as the head and neck area.

• Caution is advised when using local anesthetics in this area due to the potential for systemic toxicity and adverse reactions.
• It is essential to carefully evaluate the patient's condition and consider alternative options before using lido-epi in the head and neck area 2.

From the Research

Safety of Using Lidocaine with Epinephrine for Forehead Laceration

• The use of lidocaine with epinephrine for forehead lacerations has been studied in various clinical trials 3, 4, 5, 6.
• These studies suggest that lidocaine with epinephrine can be effective in reducing pain during laceration repair, with some studies showing significant reductions in pain scores 4, 5, 6.
• However, there is also a risk of complications, such as necrosis, particularly in areas with limited blood supply, as reported in a case series of eyelid necrosis after injection of lidocaine with epinephrine 7.
• The risk of necrosis is thought to be due to prolonged vasoconstriction caused by the epinephrine, and is more likely to occur in patients with pre-existing vascular conditions 7.

Considerations for Use

• The decision to use lidocaine with epinephrine for a forehead laceration should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 7.
• Alternative methods of anesthesia, such as topical lidocaine without epinephrine, may be considered for patients at high risk of complications 5, 6.
• The use of lidocaine with epinephrine should be carefully monitored, and patients should be followed up to assess for any potential complications 3, 4, 5, 6.