see also [[Sodium channel blocker]], [[Methemoglobinemia]] [goldfrank local anaesthetics](x-devonthink-item://2F041FBD-FF1C-4E21-9CD5-5550C288F006?page=1020), [Austin - Local anaesthetic toxicity](x-devonthink-item://4ABE87B6-D578-4589-B38D-70B1AB1FE6F3) Antidote:: [[Intralipid]] # Mechanism Bupivicaine most cardiotoxic (dose supposed to be 2mg/kg) Bupivacaine is particularly cardiotoxic due to prolonged binding to myocardial tissue. > Best evidence for [[#Intralipid]] > 4 stages ![[Pasted image 20241016110544.png]] ## CNS - dizziness - Tinnitus - Perioral tingling - Unresponsiveness ## Seizures - usually self-limiting due to drug re-distribution - Benzos help ## CNS depression ## Cardiovascular - hypotension - Arrhythmia Can also cause [[Methemoglobinemia]] # Treatment 1. ensure airway patent 2. if bier's block, ensure cuff stays up 3. midaz 1-5 mg terminate seizure 4. ensure no arrhythmia or hypoglycaemia 5. [[HCO3 therapy|sodium bicarb]] 1-2 mmol/kg IV if ventricular arrhythmias 6. [[Intralipid|Lipid emulsion]] 1.5mL/kg bolus if *cardiovascular collapse* and arrhythmias refractory to standard measures (aka severe cardiovascular toxicity) ## Hco3 ## Midazolam for seizures ## Intralipid - 1.5 mL/kg bolus 1 min, q5min for up to three doses - infusion 15mL/kg/hour until CVS stability obtained - do not exceed 12 mL/kg cumulative dose Treat methemoglobinemia with [[Methylene blue]] # Controversies # Related Questions ## local anaesthetic toxicity - [ ] 17Q: [Median Nerve Block](x-devonthink-item://EE8AC47E-BE40-4377-885E-FA9C91C8C262?page=11) -- [Answer]() - [ ] 18Q: [Local Anaesthetic Toxicity](x-devonthink-item://EDAB8F09-3068-4C91-874B-E205EA17F631?page=4) -- [Answer](x-devonthink-item://E624826E-2062-41B8-96C9-ECEA0E1BDF54?page=3) - [ ] 19Q: [Bupivicaine Toxicity](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=40) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=26) - [ ] 20Q: [Bupivicaine Toxicity](x-devonthink-item://EB2A381E-D8D3-4236-B51F-2DF81CE08885?page=13) -- [Answer](x-devonthink-item://8455B512-D9BD-4314-927B-D3208619EE2A?page=12) ## prilocaine toxicity - [ ] 22Q: [Prilocaine Toxicity](x-devonthink-item://078484BD-EA8D-4380-B88A-19048B494073?page=6) -- [Answer](x-devonthink-item://16D9B527-CEE4-41A5-B147-D3AE54CBF312?page=4)