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Various toxicities: case report A 22-year-old woman developed local anaesthetic systemic toxicity followed by haemodynamic instability, pulmonary oedema, left ventricular dysfunction and prolonged pulseless electrical activity cardiac arrest following induction of local anaesthesia with lidocaine and epinephrine. The woman was scheduled for cosmetic rhinoplasty under general anaesthesia. General anaesthesia was induced with propofol and remifentanil. She was intubated with an endotracheal tube and ventilation was initiated. Anesthesia was maintained with infusions of remifentanil and propofol. After achieving haemodynamic stability, 6mL of 2% lidocaine (120mg) with epinephrine 15 µg/mL was injected in the submucosa of the middle and distal parts of the posterior nasal cavity for induction of local anaesthesia. Approximately 20 seconds after the administration of injection, she developed tachycardia and hypertension. Within few seconds, oxygen saturation and noninvasive blood pressure measurements were lost with no palpable carotid or femoral pulses. Initially, exhaled CO2 tracing was normal, but she appeared ashen and was presumed to have pulseless electrical activity. Her propofol and remifentanil infusions were stopped. The woman was treated as per standard advanced cardiac life support protocol, along with chest compressions. A defibrillator revealed pulseless electrical activity and narrow complex tachycardia. Over the next 10 minutes, she was treated with IV epinephrine 1mg twice and amiodarone. The femoral arterial line was placed. After 2 minutes, the ECG showed ventricular tachycardia. Despite synchronized cardioversion with 200 J, she reverted back to pulseless electrical activity. During the resuscitative efforts, her exhaled CO2 level varied between 35 and 50mm Hg. Seventeen minutes after the initiation of advanced cardiac life support, she became pulseless and had foamy secretions in the endotracheal tube. A local anaesthetic systemic toxicity was suspected; hence, she was treated with lipid emulsion. Over the next 4 minutes, her haemodynamic status improved. Twenty six minutes after the initial cardiac arrest, return of spontaneous circulation was achieved, and after 4 minutes, she was extubated. Her laboratory parameters also normalised after one day. Initial ECG had shown left ventricular dysfunction, which recovered after 4 days. She had also developed pulmonary oedema during admission, which was treated with continuous use of positive airway pressure machine for several days. Five days later, she was discharged from hospital without any neurologic sequelae. Author comment: "This case demonstrates that local anesthetic systemic toxicity with cardiac arrest can occur even after exposure to a very low dose of local anesthetics, including lidocaine, a "less lipophilic" local anesthetic when given in an epinephrine containing solution." Weber F, et al. Prolonged Pulseless Electrical Activity Cardiac Arrest After Intranasal Injection of Lidocaine With Epinephrine: A Case Report. A and A Practice 12