Local Anesthetic Systemic Toxicity

High risk of serious Arrhythmia or Cardiac Arrest if injected intravascularly
Bupivicaine (and Ropivacaine) are much more toxic systemically than Lidocaine
1. Highly lipophilic
2. High Sodium channel affinity

ABC Management
Seizure Management
1. See Status Epilepticus
2. Benzodiazepines are preferred first-line agents
3. Avoid Propofol (due to hemodynamic instability)
Arrhythmia Management
1. See ABC Management (follow ACLS protocols)
2. Avoid Vasopressin, Calcium Channel Blockers, Beta Blockers
3. Decrease Epinephrine dose to 1 mcg/kg
4. Give Sodium Bicarbonate if Wide Complex Tachycardia (similar to Tricyclic Overdose)
Intralipid 20% emulsion
1. Bolus 1.5 ml/kg (Lean Body Mass) IV push over 2 minutes
  1. May repeat in 2-3 minutes for refractory cardiovascular collapse
  2. If still not effective may start Intralipid infusion as below
2. Continuous infusion 0.25 ml/kg/min for at least 10 min after circulatory stability
  1. May increase to 0.50 ml/kg/min if persistent Hypotension
  2. May increase to maximum of 10-15 ml/kg
  3. Alternatively, 15 ml/kg may be infused over 1 hour
3. See Intravenous Lipid Emulsion
4. Primarily for lipophilic drug toxicity (esp. bupivicaine)
5. Draw blood tubes before injecting Intralipid (alters lab values)

Withdraw first, when injecting Anesthetic, especially for bupivicaine (to prevent intravascular injection)
Adding Epinephrine to the Local Anesthetic keeps the agent in the tissues with less systemic absorption
Limit Local Anesthetic to their maximums (calculate the maximum cc of Local Anesthetic that may be used)
1. See Regional Anesthesia
2. Lidocaine: 4 mg/kg (7 mg/kg if with Epinephrine)
  1. Lidocaine 1% contains 10 mg/ml, and 2% contains 20 mg/ml
3. Bupivacaine: 2 mg/kg
  1. Bupivacaine 0.25% contains 2.5 mg/ml, and 0.5% contains 5 mg/ml
4. Ropivacaine 3 mg/kg
  1. Ropivacaine 0.2% contains 2 mg/ml, and 0.5% contains 5 mg/ml
Be aware of high risk locations for local injections (esp. with bupivicaine)
1. Intercostal Nerve Blocks