High Dose IV Lidocaine vs Hydromorphone for Abdominal Pain in the Emergency Department
High Dose IV Lidocaine vs Hydromorphone for Abdominal Pain in the Emergency Department
Intravenous lidocaine will be given at a dose of 2 mg/kg intravenously to patients in the
 emergency department with a diagnosis of acute abdominal pain. Its efficacy will be compared
 to 1 mg of intravenous hydromorphone, with a primary endpoint of mean improvement of pain at
 90 minutes.
Abdominal pain is a common chief complaint for patients presenting to the emergency
 department (ED) in the United States. Intravenous opioids are commonly used to treat acute
 abdominal pain in the ED. These medications are highly efficacious and, when used in a
 monitored setting such as the ED, extremely safe. Use of opioids has fallen out of favor
 because of a spike in opioid-related overdose deaths throughout the United States. While use
 of opioids in the ED is unlikely to contribute to outpatient opioid deaths, minimizing the
 use of opioids in the ED will contribute to an opioid free culture, in which opioids are used
 only when absolutely necessary. A variety of different types of medications can be used in
 lieu of opioids. One such medication, intravenous lidocaine, has been used extensively for
 neuropathic pain, in the peri- and post-operative surgical setting, the cardiac care unit,
 and most recently in the emergency department.

 Intravenous lidocaine has long been used to treat pain. In publications dating back to 1980,
 intravenous lidocaine has been shown to be an effective treatment for neuropathic pain. In
 the postoperative setting, intravenous lidocaine decreased pain and decreased the need for
 opiates. More recently, emergency medicine investigators in Iran demonstrated that
 intravenous lidocaine decreased pain associated with renal colic and limb ischemia. An
 ED-based study in the United States showed comparable efficacy between morphine and
 intravenous lidocaine when used for acute pain. Most recently, a prospective RCT showed 120
 mg of intravenous lidocaine was efficacious for abdominal pain, albeit not as effective as 1
 mg of hydromorphone. However, a subgroup analysis showed that when lidocaine was dosed at 2
 mg/kg, it was equally as effective as hydromorphone.

 Over the years, intravenous lidocaine has been used for a variety of indications including
 arrhythmia prophylaxis in patients with acute coronary syndromes. Known side effects of
 intravenous lidocaine range from transient neurological symptoms (dizziness, paresthesias),
 to cardiac dysrhythmias and seizure. To date, no deaths have been attributed to its use for
 treating pain, and the only documented significant complication was due to an unintentional
 overdose when a patient received ten times the normal dose. All reported side effects in pain
 patients have been transient and resolved by either stopping the drug, decreasing the
 infusion rate or by observation alone. Additionally, doses of 2 mg/kg have been tolerated
 well in the outpatient setting, operating room and ED without any serious side effects. Thus,
 intravenous lidocaine is an emerging medication for safe and rapid relief of pain, has no
 known addictive properties, and creates a potential for a pain practice paradigm shift in the
 United States.

 We therefore propose a randomized, double blind, comparative efficacy trial to address the
 following aim:

 To determine if a 2 mg/kg dose of intravenous lidocaine is as equally efficacious as a single
 dose of 1 mg intravenous hydromorphone for acute abdominal pain in the emergency department.
Inclusion Criteria:

 -  Must be a patient in the emergency department (ED)

 -  Must have acute abdominal pain, defined as abdominal or flank pain of a duration of 7
 days or less

 -  Predicted treatment must include the use of an intravenous opiate

 Exclusion Criteria:

 -  Cardiac conduction system impairment (QTc duration > 0.5s, QRS duration > 0.12s, PR
 interval <0.12s or > 0.2s)

 -  Known renal (CKD >2) or liver disease (Childs-Pugh B or greater)

 -  Hemodynamically instability, defined by the attending physician

 -  Pregnant or breastfeeding

 -  Have a known allergy to either medication

 -  Used of prescription or illicit opioids within the previous week

 -  Patients with a chronic pain disorder, defined as use of any analgesic medication on
 more days than not during the four weeks preceding the acute episode of pain