Which statement best addresses management of suspected local anesthetic systemic toxicity (LAST)?

• A. Stop local anesthetic, secure airway, administer lipid emulsion therapy per protocol, and support hemodynamics
• B. Administer epinephrine alone
• C. Continue local anesthetic as planned
• D. Lipid emulsion therapy should be given only after airway is secured

Answer: (D)

In suspected LAST, the priority is rapid stabilization and treatment with lipid emulsion therapy right away, while you address airway and breathing. The local anesthetic toxicity can progress quickly, so you don’t want to wait to secure the airway before starting antidotal therapy. Treating with lipid emulsion acts as a lipid sink that helps pull the circulating anesthetic out of the tissues and heart, improving hemodynamics and neurologic function even as you continue airway support.

So, stop the local anesthetic, secure the airway if needed (and give high‑flow oxygen), and initiate lipid emulsion therapy per protocol as soon as LAST is suspected. A typical approach is a 20% lipid emulsion bolus followed by an infusion, with dosing adjusted to the patient’s response, and you provide ongoing hemodynamic support. Seizures are treated with benzodiazepines, and other resuscitation steps follow standard ACLS guidance, but the key point is administering lipid emulsion promptly rather than waiting for the airway to be fully secured. Delaying its administration reduces the effectiveness of this antidote and can worsen outcomes.