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)

Practice free in your browser2,450+ exam-style questions with rationales. No account, no ads. Also free on the App Store and Google Play.

For education and exam preparation only. Follow your institution’s protocols. Study aid with typical adult values; follow your local protocols and medical direction, and current AHA guidelines.