Local anaesthetic systemic toxicity can present as perioral tingling, tinnitus, agitation or confusion, then seizures, or go straight to arrhythmia and cardiovascular collapse, especially with bupivacaine. It can occur up to an hour after the block.
Management is established: stop injecting, call for help, maintain the airway with oxygen, treat seizures with a benzodiazepine, and give 20% lipid emulsion early, starting with a bolus of 1.5 mL/kg over a minute, followed by an infusion. Cardiac arrest from local anaesthetic toxicity may need prolonged resuscitation. Every area where blocks are performed should have lipid emulsion and the guideline to hand.
- Stop injecting at the first sign of toxicity and call for help.
- Give 20% lipid emulsion early: 1.5 mL/kg bolus, then infusion.
- Treat seizures with a benzodiazepine and support the airway with oxygen.
- Keep lipid emulsion and a toxicity guideline wherever blocks are done.
- Continue resuscitation for longer than usual if arrest occurs.
Why it matters
Delay in giving lipid is the avoidable part of a rare but lethal complication.
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