Regarding the management of local anesthetic systemic toxicity (LAST), all of the following are true EXCEPT:

## Local Anesthetic Systemic Toxicity (LAST) — Management Principles ### Overview of LAST Management **Key Point:** LAST is a rare but life-threatening complication of local anesthetic overdose or intravascular injection. Management is multimodal and time-sensitive. ### Correct Management Strategies | Step | Action | Rationale | |------|--------|----------| | **Immediate** | Stop injection, call for help, position supine | Prevent further drug absorption | | **Airway** | Secure airway, 100% O₂, hyperventilate | Prevent hypoxia and acidosis (which worsens toxicity) | | **Seizures** | Benzodiazepines (preferred) or propofol | Avoid succinylcholine due to risk of hyperkalemia and rhabdomyolysis | | **Lipid Emulsion** | 20% lipid emulsion IV bolus + infusion | Sequesters lipophilic local anesthetic | | **CPR** | Prolonged (>1 hour if needed) | Lipid sequestration delays drug elimination | ### Why Succinylcholine Is Contraindicated in LAST **Warning:** Succinylcholine is **NOT** first-line for LAST-induced seizures because: 1. Local anesthetics (especially bupivacaine) cause myotoxicity and rhabdomyolysis 2. Succinylcholine triggers massive K⁺ release from damaged muscle → severe hyperkalemia → cardiac arrest 3. Benzodiazepines (midazolam, lorazepam) or propofol are preferred seizure agents **High-Yield:** The classic teaching is: **"Avoid succinylcholine in LAST; use benzodiazepines or propofol."** ### Lipid Emulsion Therapy **Clinical Pearl:** Lipid emulsion is a lipophilic "sink" that: - Redistributes local anesthetic away from cardiac and CNS tissue - Is given as a 1.4 mL/kg bolus of 20% emulsion over 1 minute - Followed by infusion at 15 mL/kg/min - Can be repeated if cardiovascular instability persists ### Prolonged CPR in LAST **Key Point:** Unlike typical cardiac arrest, LAST may require CPR for >1 hour because: - Lipid sequestration slows drug elimination - Patients have recovered with good neurological outcome after prolonged resuscitation - Do not abandon resuscitation prematurely [cite:Barash Clinical Anesthesia 8e Ch 14]