A 56-year-old woman underwent an uncomplicated left shoulder bone spur removal under general anesthesia with 2 mg of versed, 100 mcg of fentanyl, 150 mg of propofol, and sevoflurane in an outpatient surgery center. After completion of the procedure, the anesthesiologist performed an interscalene nerve block for post-operative pain control utilizing 30 mL of bupivacaine (0.25%). Approximately 5 min after completion of the block, the patient developed bilateral mydriasis, paralysis of all extremities, and respiratory arrest. The patient was immediately intubated, administered IV fluids, ephedrine 15 mg IV, and transferred to an emergency department (ED).\nOn ED arrival the patient was being ventilated through an oral endotracheal tube and was completely paralyzed. Her vital signs were: blood pressure (BP) 108/56 mmHg; pulse 86 per minute; respiratory rate 24 breaths per minute on a ventilator. Her pupils were 6 mm and unresponsive to light bilaterally. She had no response to painful stimulation and had no spontaneous respirations on a ventilator. Her initial blood tests included a complete blood count, electrolytes, liver function tests, cardiac enzymes, and coagulation tests. The lab results were all unremarkable except for a phosphorus of 1.7 mg/dL and lactate of 4 mmol/L. In the ED she was administered a 1-L normal saline bolus and 20% intravenous lipid emulsion 85 mg. Over the next 4 h, the patient progressively regained motor and sensory functions followed by successful extubation in the ED. She was admitted to the hospital for observation and discharged home the next day without any neurologic sequelae.
A 15 year old girl presented to the ER with coma following several tonic–clonic convulsions.\nThe patient was previously healthy with no personal or familial medical history. During her visit to a dentist for endodontic treatment, the dentist injected 1.5 ml of 2 % lidocaine (the total dose was 30 mg) and epinephrine 1:100,000 for local anesthesia. The solution was injected on the left side by an expert hand without prior aspiration.\nThe injection lasted about 2 min. By the end of the injection, the girl collapsed and several intermittent tonic–clonic convulsions ensued. These lasted about 30 min and were followed by deep coma.\nGlasgow coma scale (GCS) was three, brainstem reflexes were intact, and no fever was noticed. Vital signs were within normal limits.\nHer left cheek and gingiva were edematous and a giant gingival hematoma was noticed.\nOptic disc examination showed no edema.\nElectrocardiogram (ECG) was normal except for sinus tachycardia (120 beat per minute).\nElectroencephalography (EEG) showed diffuse slow activity, predominately theta rhythms, with no signs of continuous status epilepticus.\nBrain computed tomography (CT) revealed reduced white–gray matter differentiation with effacement of cerebral sulci which was compatible with cerebral edema.\nBrain magnetic resonance imaging with venogram (Fig. ) and angiogram (Fig. ) MRI + MRV + MRA showed cerebral edema, bilateral and almost symmetric hyperintense T2 lesions with restricted diffusion in both frontal and occipital lobes (Fig. ), and no underlying cerebral venous thrombosis CVT.\nLumbar puncture was performed and revealed the following results: 10 lymphocytes, elevated protein (50 mg/dl), no RBCs, and negative gram stain. Whereas blood glucose was 50 mg/dl, CSF glucose was 70.\nOrdinary labs including Calcium, Albumin, MG, Na, K, creatinine, urea, LFTs, CBC, Plt, PT, PTT, and INR were all normal and troponin was negative.\nThe patient was admitted to the ICU and intubated.\nPhenytoin at dose 15 mg/kg was loaded with close cardiac monitoring, and a maintenance dose of 100 mg twice daily was initiated in the second day.\nA bolus (1 g/kg) of Mannitol was given intravenously, followed by a maintenance dose of 0.5 g/kg/8 h. GCS, consequently, improved to nine in 2 days.\nThe patient recovered completely and was discharged after a week of admission.