Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Signs and symptoms suggestive of local anesthetic systemic toxicity (LAST)
History of Present Illness:
Briefly describe the procedure where local anesthesia was used (e.g., dental procedure, central line placement, infiltration for laceration repair).
Mention the specific local anesthetic used (e.g., lidocaine, bupivacaine) and the estimated dose administered.
Inquire about the onset and progression of symptoms suggestive of LAST (e.g., perioral numbness, tinnitus, metallic taste, twitching, seizures, hypotension, arrhythmias).
Past Medical History:
Include any relevant past medical history, such as:
Pre-existing neurological conditions (e.g., epilepsy)
Cardiovascular disease (may increase risk of arrhythmias from LAST)
Liver or kidney disease (can affect metabolism and elimination of local anesthetics)
Allergies to local anesthetics (rare)
Medications:
List all current medications, including any medications that can interact with local anesthetics (e.g., CYP3A4 inhibitors).
Social History:
Inquire about substance abuse (cocaine use can increase risk of LAST).
Family History:
Not typically relevant for LAST, but can be included if pertinent.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Neurological exam: Assess mental status (alertness, confusion), presence of tremors, fasciculations, or seizures.
Cardiovascular exam: Evaluate for heart rate and rhythm abnormalities.
Respiratory exam: Assess for respiratory depression or difficulty breathing.
Laboratory Tests (if performed):
Mention relevant laboratory findings, depending on the clinical presentation:
Arterial blood gas (ABG): May be necessary if respiratory depression is suspected.
Electrolytes (sodium, potassium): Abnormalities can worsen cardiac arrhythmias.
Treatment:
Outline the treatment plan initiated based on the severity of LAST symptoms:
Supportive care: Maintaining airway, breathing, and circulation is the priority.
Seizure management: Anticonvulsant medications if seizures occur.
Cardiac arrhythmia management: Medications or procedures depending on the specific arrhythmia.
Vasopressors: Medications to increase blood pressure if hypotension is present.
Lipid resuscitation: Administration of intravenous lipid emulsion ( controversial but may be considered in severe cases)
Imaging Studies (if performed):
Not typically obtained for the diagnosis of LAST, but imaging studies like electrocardiogram (ECG) may be performed to assess for cardiac arrhythmias.
Assessment:
Diagnosis: State the suspected or confirmed diagnosis of local anesthetic systemic toxicity based on clinical presentation and potential supportive laboratory findings.
Severity: Briefly describe the perceived severity of LAST based on the presenting symptoms and hemodynamic stability.
Plan:
Continued monitoring: Close observation in a monitored setting (ICU may be necessary) until complete resolution of LAST symptoms.
Supportive care: Continue with measures to maintain airway, breathing, and circulation as needed.
Specific treatment for complications: Address any ongoing complications like seizures or arrhythmias.
Consultation: Consider consulting with a toxicologist or critical care specialist for complex cases.
Follow-up:
Depending on the severity of LAST, the patient may require extended hospitalization for monitoring and management.
Schedule follow-up clinic visits to assess for any potential long-term neurological sequelae.