Metabolic, toxicology and environment

Local Anesthetic Toxicity Algorithm

Seizures, arrhythmias and lipid emulsion

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Recognize LAST

After a nerve block, epidural, large-volume lidocaine or bupivacaine
Early: perioral numbness, metallic taste, tinnitus, agitation
Then seizures, bradycardia, wide QRS, ventricular arrhythmias, cardiac arrest

Suspected → step 2

2 Stop and support

Stop the local anesthetic; call for help and the LAST kit
Airway and 100% oxygen; avoid hypoxia and acidosis
Seizures: benzodiazepine (avoid large propofol doses if unstable)

Give lipid emulsion → step 3

3 20% lipid emulsion

Over 70 kg: 100 mL bolus over 2–3 minutes, then 200–250 mL over 15–20 minutes
70 kg or less: 1.5 mL/kg bolus, then 0.25 mL/kg/min
Repeat bolus once or twice and double the infusion if still unstable; maximum about 12 mL/kg

Cardiac arrest → step 4

4 Arrest from LAST

CPR; epinephrine in small doses (1 mcg/kg or less)
Avoid vasopressin, calcium channel blockers, beta-blockers and other local anesthetics (lidocaine)
Prolonged CPR is reasonable; contact a center that can start ECMO

End of this path.

Drugs in this algorithm

Related one-pagers

ACLS Algorithms in BriefSpecial circumstances and ECPR: Local anesthetic toxicity: Lipid emulsion 20%; smaller epinephrine doses: 1.5 mL/kg bolus; epinephrine ≤1 mcg/kg (ASRA 2020)

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