[New post] “LAST [Local Anesthetic Systemic Toxicity], prevention, recognition, and management” from EM Quick Hits 26its
Tom Wade MD posted: "In this post, I link to and post the show notes from LAST [Local Anesthetic Systemic Toxicity], prevention, recognition, and management from EM Quick Hits 26 LAST, Sodium Nitrite Poisoning, Post-intubation Care, Tetracaine for Corneal Abrasion, ST Segment" Tom Wade MD
Salim Rezaie on short-term tetracaine for corneal abrasions new evidence (25:58)
Jesse MacLarenon differentiating ST deviation in occlusion MI from other causes (33:03)
Robert Maunder on a 3 step approach to coping and building resilience during the COVID pandemic (40:52 )
*Helman, A. Swaminathan, Austin, E. M. Rosenberg, H. Rezaie, S. MacLaren, J. Maunder, R. EM Quick Hits 26 – LAST, Sodium Nitrite Poisoning, Post-intubation Care, Tetracaine for Corneal Abrasion, ST depression, Coping with COVID. Emergency Medicine Cases. February, 2021. https://emergencymedicinecases.com/em-quick-hits-february-2021/. Accessed 9-30-2022.
All that follows is from Dr. Swaminathan's LAST [Local Anesthetic Systemic Toxicity], prevention, recognition, and management.
LAST (Local Anesthetic Systemic Toxicity) is an iatrogenic life-threatening acute neurologic/cardiac adverse reaction resulting from infiltration of local anesthetic that enters the systemic circulation
The best treatment is prevention! Preventative measures include aspirating before injection of anesthetic to ensure that the needle is not in a blood vessel and using less than the toxic dose of the anesthetic (see table below)
Consider LAST in any patient coming from outpatient surgical center in cardiac arrest
Initial symptoms/signs include perioral numbness and other paresthesias, tinnitus, muscle fasciculations, hypertension, tachycardia progressing to tonic-clonic seizures, decreased LOA, apnea, hypotension, bradycardia, dysrhythmias and cardiac arrest
Neurologic symptoms typically precede cardiovascular symptoms in lidocaine toxicity while cardiovascular symptoms typically present first in bupivacaine toxicity
Treatment in addition to withdrawal of anesthetic and usual CABs may include epinephrine, bicarb, lipid emulsion therapy
Local anesthetic maximum doses adapted from Core EM
References
Schwartz DR, Kaufman B. Local Anesthetics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015.
Neal JM et al, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8.
Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97.
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