Local Anaesthetic Toolkit

Info

Symptoms and Signs

Initial symptoms: circumoral tingling, tinnitus, metallic taste, dizziness, dysphoria, dysarthria

Signs of severe toxicity: Agitation and reduced GCS, with or without convulsions. Cardiovascular collapse including brady- and tachy-arrhythmias

LA toxicity may occur some time after injection

Severe Toxicity: Initial Management

Stop giving LA and get help

Maintain airway (intubate if necessary) and give 100% oxygen. Consider hyperventilation

Confirm / establish IV access

Control seizures with small incremental doses of benzodiazepine, thiopental or propofol

Reassess ABC

Draw blood for analysis if able to do so without delaying treatment

Management (without cardiac arrest)

Continue as above

Treat hypotension / arrhythmias as appropriate (don't use lidocaine for arrhythmia)

Consider intravenous lipid emulsion (propofol is not a suitable substitute)

Management in cardiac arrest

Commence CPR using standard protocols

Treat arrhythmias. Arrhythmias may be very refractory to treatment

Do not use lidocaine to treat arrhythmias

Arrest likely to be prolonged

Consider cardiopulmonary bypass if available

Give intravenous lipid emulsion

Lipid emulsion regimen

Selected weight: kg:

Give intravenous lipid emulsion (20%) at initial bolus of 1.5 ml/kg = ml

Commence infusion at 15 ml/kg/hr = ml/hr

After 5 minutes, if cardiovascular stability not restored or deteriorates, repeat the bolus: ml and increase the rate of infusion to 30 ml/kg/hr = ml/hr

After another 5 minutes if cardiovascular stability not restored or deteriorates, repeat the bolus for a final time: ml

Continue infusion until the patient's condition improves

Do not give more than 12 ml/kg TOTAL = ml

Links and References

AAGBI Safety Guideline for management of severe local anaesthetic toxicity

A printable poster of doses and management of toxicity, including nomogram. From Williams DJ, Walker JD. A nomogram for calculating maximum dose of local anaesthetic. Anaesthesia 2014 doi 10.1111/anae.12679