Medication Summary
The goals of pharmacologic therapy in patients with neurologic toxicity from local anesthetic agents are to terminate the neuromuscular and cerebral manifestations.
Anticonvulsants, Barbiturates
Class Summary
These agents terminate seizures.
Pentobarbital (Nembutal)
A short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties, pentobarbital can produce all levels of CNS mood alteration.
Phenobarbital (Luminal)
Phenobarbital interferes with the transmission of impulses from the thalamus to the cerebral cortex. In the emergent setting, phenobarbital is typically used when benzodiazepines fail to abort status epilepticus.
Anxiolytics, Benzodiazepines
Class Summary
These agents terminate seizures. By binding to a specific receptor site, these agents appear to potentiate the effects of gamma-aminobenzoic acid (GABA) and to facilitate inhibitory GABA neurotransmission and other inhibitory neurotransmitters.
Diazepam (Valium, Diastat, Diastat AcuDial)
Diazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of GABA. Diazepam diminishes or terminates seizures. Individualize dosage and increase cautiously to avoid adverse effects.
Midazolam
Midazolam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. It diminishes or terminates seizures. Midazolam is shorter acting and more potent than diazepam. Individualize dosage and increase cautiously to avoid adverse effects.
Neuromuscular Blockers, Depolarizing
Class Summary
These agents terminate the neuromuscular manifestations of seizures.
Succinylcholine (Anectine, Quelicin)
Succinylcholine causes paralysis of airway and respiratory muscles; apnea ensues. Establishing and maintaining an airway and ventilation are mandatory prerequisites.
Tables
Solution Volume |
1:100,000 (1 mg/100 mL) |
1:200,000 (1 mg/200 mL) |
1 mL |
0.01 mg |
0.005 mg |
5 mL |
0.05 mg |
0.025 mg |
10 mL |
0.1 mg |
0.05 mg |
20 mL |
0.2 mg |
0.1 mg |
Example: 50 mL of 1% lidocaine with epinephrine 1:100,000 contains lidocaine 500 mg and epinephrine 0.5 mg. |
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Agent |
Duration of Action |
Maximum Dosage Guidelines (Total Cumulative Infiltrative Injection Dose per Procedure*) |
Esters |
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Procaine (Novocaine) |
Short (15-60 min) |
7 mg/kg; not to exceed 350-600 mg |
Chloroprocaine (Nesacaine) |
Short (15-30 min) |
Without epinephrine: 11 mg/kg; not to exceed 800 mg total dose With epinephrine: 14 mg/kg; not to exceed 1000 mg |
Amides |
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Lidocaine (Xylocaine) |
Medium (30-60 min) |
Without epinephrine: 4.5 mg/kg; not to exceed 300 mg |
Lidocaine with epinephrine |
Long (120-360 min) |
With epinephrine: 7 mg/kg |
Mepivacaine (Polocaine, Carbocaine) |
Medium (45-90 min) Long (120-360 min with epinephrine) |
7 mg/kg; not to exceed 400 mg |
Bupivacaine (Marcaine) |
Long (120-240 min) |
Without epinephrine: 2.5 mg/kg; not to exceed 175 mg total dose |
Bupivacaine with epinephrine |
Long (180-420 min) |
With epinephrine: Not to exceed 225 mg total dose |
Etidocaine (Duranest) No longer available in United States |
Long (120-180 min) |
Without epinephrine: 0.4 mg/kg; not to exceed 300 mg total dose With epinephrine: 8 mg/kg |
Prilocaine (Citanest) |
Medium (30-90 min) |
Body weight < 70 kg: 8 mg/kg; not to exceed 500 mg Body weight >70 kg: 600 mg |
Ropivacaine (Naropin) |
Long (120-360 min) |
5 mg; not to exceed 200 mg for minor nerve block |
*Nondental use, administer by small incremental doses; administer the smallest dose and concentration required to achieve desired effect; avoid rapid injection. |
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Agent |
Minimum Toxic Dose (mg/kg) |
Procaine |
19.2 |
Tetracaine |
2.5 |
Chloroprocaine |
22.8 |
Lidocaine |
6.4 |
Mepivacaine |
9.8 |
Bupivacaine |
1.6 |
Etidocaine |
3.4 |
