Acute emergencies from local anesthetics are generally related to high plasma levels or high dermatomal levels ("high spinal") encountered during therapeutic use of local anesthetics or to unintended intrathecal or intravascular injection of local anesthetic solution (see ADVERSE REACTIONS, WARNINGS, and PRECAUTIONS ). There was one case of suspected unintentional intravascular injection which occurred during the clinical trial program. That patient received 19 mL of 0.75% levobupivacaine (142.5 mg) and experienced CNS excitation which was treated with thiopental. No abnormal cardiovascular changes were observed and the patient recovered without sequelae.

Management of Local Anesthetic Emergencies

The first consideration is prevention, best accomplished by incremental injection of Chirocaine, careful and constant monitoring of cardiovascular and respiratory vital signs and the patient's state of consciousness after each local anesthetic injection and during continuous infusion. At the first sign of change, oxygen should be administered.

The first step in the management of systemic toxic reactions, as well as under-ventilation or apnea due to unintentional subarachnoid injection of drug solution, consists of immediate attention to the establishment and maintenance of a patent airway and effective assisted or controlled ventilation with 100% oxygen with a delivery system capable of permitting immediate positive airway pressure by mask. This may prevent convulsions if they have not already occurred.

If necessary, use drugs to control convulsions. Intravenous barbiturates, anti-convulsant agents, or muscle relaxants should only be administered by those familiar with their use. Immediately after the institution of these ventilatory measures, the adequacy of the circulation should be evaluated. Supportive treatment of circulatory depression may require administration of intravenous fluids, and, when appropriate, a vasopressor dictated by the clinical situation (such as ephedrine or epinephrine to enhance myocardial contractile force).

If difficulty is encountered in the maintenance of a patent airway or if prolonged ventilatory support (assisted or controlled) is indicated, endotracheal intubation, employing drugs and techniques familiar to the clinician, may be indicated after initial administration of oxygen by mask.

The supine position is dangerous in pregnant women at term because of aortocaval compression by the gravid uterus. Therefore, during treatment of systemic toxicity, maternal hypotension or fetal bradycardia following regional block, the parturient should be maintained in the left lateral decubitus position if possible, or manual displacement of the uterus off the great vessels should be accomplished. Resuscitation of obstetrical patients may take longer than resuscitation of non-pregnant patients and closed-chest cardiac compression may be ineffective. Rapid delivery of the fetus may improve the response to resuscitation efforts.

Chirocaine is contraindicated in patients with a known hypersensitivity to Chirocaine or to any local anesthetic agent of the amide type.

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