Local anaesthetic systemic toxicity often starts with perioral tingling, tinnitus, metallic taste or agitation, then seizures, then arrhythmia and cardiovascular collapse — though with bupivacaine the heart can go first. Twenty per cent lipid emulsion works best when given at the first sign of serious toxicity, not held until cardiac arrest. Every area that performs blocks needs it within reach.
- Stop injecting at the first symptom and call for help.
- Give 20% lipid emulsion 1.5 mL/kg IV over 2–3 minutes (100 mL bolus if over 70 kg, per ASRA), then an infusion of 0.25 mL/kg/min.
- Repeat the bolus up to twice and double the infusion rate if instability persists; do not exceed about 12 mL/kg in total.
- Treat seizures with a benzodiazepine; avoid large doses of propofol in a haemodynamically unstable patient.
- In arrest, reduce adrenaline doses to 1 microgram/kg or less and continue CPR for longer than usual.
Why it matters
Case reports suggest early lipid can prevent progression to arrest; delay is the modifiable error.
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