Episode 95.0 – Local Anesthetic Systemic Toxicity (LAST)

This week we discuss the identification, prevention and treatment of local anesthetic systemic toxicity.

May 1st, 2017 Download 6 Comments Tags: , , , ,

Show Notes

LITFL: Local Anesthetic Toxicity

Wiki EM: Local Anesthetic Systemic Toxicity


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. Link

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. PMID: 22189574

Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97. PMID: 25534900


  • Roger Helmers, DVM says:

    The toxic dose for lidocaine is mentioned as being 5 mg/kg but I believe that is the upper end of the therapeutically acceptable dose, which is quite a bit lower than the actual toxic dose.

  • Hassan A says:

    Thanks. If lidocaine is used intravenously for cardiac areythmia, why should i fear of injecting lidocaine iv or arterial !

    • Anand Swaminathan, MD says:

      With IV administration of lidocaine, you are well below the toxic dose. The dose of cardiac lidocaine is 1.5 mg/kg. The toxic dose is 5 mg/kg.

  • Capt. Dr. George Selvaraj says:

    Very crisp and precise presentation .

  • Anand
    Thanks for your great post. The area you did not address is the use of lidocaine for awake intubation. The toxic dose depends obviously on the method of delivery and the tissue interface to which it is applied. I recently interviewed Ian Morris an anesthetist (and EP by training) who many including me would consider one of the world’s experts on the subject of awake topicalization for intubation. His about to be published chapter Management of the Difficult Airway will I am sure be considered a definitive review on the subject with over 300 references. Check him out… http://admin.aimeairway.ca/announcement/45/sleepless-in-halifax

    • Anand Swaminathan, MD says:

      George – great point. Where would you “max out” on topical lidocaine? Hard to gauge topical absorption. We do see an occasional case coming from the endo suite with neuro symptoms after topicalization but I’ve never had an arrest from lido in this setting.

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