Lidocaine-induced cardiac arrest during CT-guided lung biopsy: a case report of local anesthetic systemic toxicity outside the operating room

Local anesthetic systemic toxicity (LAST) is an uncommon but potentially fatal complication of local anesthetic use that may occur outside the operating room and present atypically with abrupt cardiac arrest. A 78-year-old man undergoing a CT-guided core-needle biopsy of a left anterior lung mass received local infiltration with a total of 30 mL lidocaine (three divided 10 mL aliquots). Immediately after sampling he collapsed and became pulseless with absent respirations. On arrival to the emergency department, he required cardiopulmonary resuscitation; 1 mg intravenous adrenaline was given and return of spontaneous circulation was achieved after two cycles of CPR. Initial post-ROSC examination showed GCS 7/15 and unremarkable ECG and laboratory studies. On day 1 he developed slurred speech and left-sided weakness; non-contrast brain CT showed diffuse cerebral atrophy without acute infarction. The patient received advanced cardiac life support and supportive critical care measures; 20% intravenous lipid emulsion was not available. Neurologic deficits improved over 48 h and fully resolved by hospital day 3; he was discharged stable with outpatient follow-up. This case of presumed lidocaine-induced LAST with immediate cardiac arrest during a CT-guided biopsy highlights the need for vigilance for LAST in non-OR settings, adjustment of dosing in vulnerable patients, and institutional preparedness, including availability of 20% lipid emulsion and staff training, to optimize recognition and outcomes.