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S5 - Regional/OB - Test 1 > Article - ASRA Checklist > Flashcards

Article - ASRA Checklist Flashcards

1
Q

How is the pharmacologic treatment of LAST different than other cardiac arrest scenarios?

A
  • Reduce epinephrine to < 1 mcg/kg

- Avoid vasopressin, calcium channel blockers, beta blockers, or other local anesthetics

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2
Q

5 Main steps of LAST treatment

A
  1. Stop injecting local anesthetic
  2. Get help
  3. Airway management
  4. Control seizures
  5. Treat hypotension and bradycardia (if pulseless start CPR)
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3
Q

What should you consider at the first sign of SERIOUS LAST event?

A

Lipid emulsion

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4
Q

Two things you should ask for when getting help

A

LAST rescue kit

Cardiopulmonary bypass team

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5
Q

Components of airway management for LAST

A
  • Ventilate with 100% O2
  • Avoid hyperventilation
  • Advanced airway device if necessary
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6
Q

Components of controlling seizures

A
  • Benzos are preferred

- Avoid large doses of propofol especially in hemodynamically unstable patients

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7
Q

Lipid emulsion instructions in patients greater than 70 kg

A
  • Bolus 100 ml lipid emulsion 20% over 2-3 mins

- Lipid emulsion infusion 200-250 ml over 15-20 mins

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8
Q

Lipid emulsion instructions in patients less than 70 kg

A
  • Bolus 1.5 ml/kg lipid emulsion 20% over 2-3 mins

- Lipid emulsion infusion ~0.25 ml/kg/min (ideal body weight)

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9
Q

What to do if patient remains unstable after lipid emulsion?

A
  • Re-bolus once or twice at the same dose and double the infusion rate (be aware of dosing limit 12 ml/kg)
  • Total volume of lipid emulsion can approach 1 L in prolonged resuscitation (>30 mins)
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10
Q

How long to monitor LAST patient after cardiac event?

A

at least 4-6 hours

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11
Q

How long to monitor LAST patient after limited CNS event?

A

At least 2 hours

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12
Q

Dose of local anesthetic to reduce risk of LAST

A

Least dose necessary to achieve the desired extent and duration of block

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13
Q

What influences blood levels of local anesthetics?

A

Site of injection and dose

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14
Q

Patients at increased risk for LAST

A
  • Infants < 6 months
  • Small patient size
  • Advanced age and frailty
  • Heart failure
  • Ischemic heart disease
  • Conduction abnormalities or rhythm disorders
  • Metabolic (mitochondrial) disease
  • Liver disease
  • Low plasma protein concentration
  • Acidosis
  • Medications that inhibit sodium channels
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15
Q

Patients more sensitive to LAST?

A

Patients with very low ejection fractions

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16
Q

Test dose for prevention of LAST

A

Epinephrine 2.5-5 mcg/ml (total 10-15 mcg)

Know expected response, onset, duration, and limitations of test dose in identifying intravascular injection

17
Q

How to inject LA

A
  • Aspirate syringe prior to each injection while observing for blood in syringe or tubing
  • Inject incrementally, while observing for signs and symptoms of toxicity between each injection
18
Q

When should you consider discussing dose of local anesthetic?

A

During time-out

19
Q

When should you monitor patient for LAST and for how long?

A

During and after completing injection

Clinical toxicity can be delayed for 30 mins or longer

20
Q

Consider LAST in patients with what clinical symptoms?

A
  • Altered mental status
  • Neurologic symptoms
  • Signs of cardiovascular instability (i.e. change in HR, BP, ECG)
21
Q

Consider LAST even when the local anesthetic dose is? 4 things

A
  1. Small (susceptible patient)
  2. Atypically administered (subcutaneous, mucosal, topical)
  3. Administered by the surgeon
  4. After recent tourniquet deflation
22
Q

CNS signs of LAST that may be subtle, atypical, or absent

A
  1. Excitation (agitation, confusion, vocalization, muscle twitching, seizure)
  2. Depression (drowsiness, obtundation, coma, or apnea)
  3. Non-specific (metallic taste, circumoral numbness, diplopia, tinnitus, dizziness)
23
Q

CV signs of LAST (sometimes the only manifestation of severe LAST)

A

Initially may be hyperdynamic (HTN, tachycardia, ventricular arrhythmias)

Then,

  • Progressive hypotension
  • Conduction block, bradycardia, or asystole
  • Ventricular arrhythmias (v. tach, Torsades, V. fib, or asystole)
24
Q

What may abolish the patient’s ability to recognize or report LAST-related symptoms?

A

Sedation

25
Q

Suggested components of the LAST rescue kit

A
  • 1 L (total) lipid emulsion 20%
  • Several large syringes and needles for admin
  • Standard IV tubing
  • ASRA LAST checklist
26
Q

Can lipid emulsion be used for any local anesthetic drug?

A

Yes

27
Q

Why do you reduce dose of epi in LAST resuscitation event?

A

Standard dose of epinephrine can impair resuscitation and reduce efficacy of lipid rescue

28
Q

When you can proceed with surgery after LAST event?

A

If event is short-lived and without symptoms of CV instability may proceed after uneventful ~30 min interval of monitoring

S5 - Regional/OB - Test 1 (13 decks)

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