A 43-year-old male presented to the emergency department (ED) for evaluation of acute respiratory arrest. Prior to arrival, the patient was at an outpatient surgical center being prepared for a right shoulder arthroscopic surgery under regional anesthesia. The anesthesiologist injected 10 mL of bupivacaine and 30 mL of ropivacaine, of unknown concentrations, while attempting to perform an interscalene block. Soon thereafter, the patient complained of difficulty breathing and subsequently developed complete paralysis and respiratory arrest requiring emergent endotracheal intubation prior to hospital arrival. No additional medications were administered at the time of intubation.\nPhysical exam revealed dilated pupils nonreactive to light, complete flaccid paralysis and inability to withdraw from noxious stimuli. The patient immediately received two liters of 0.9% normal saline and a dopamine infusion, initiated at 5 mcg/kg/min, due to persistent bradycardia (heart rate of 44 bpm) and hypotension. The local poison control center was contacted for recommendations on potential LAT. The decision was made to administer 20% ILE, with a bolus of 125 mL (1.5 mL/kg) over one minute, about 90 minutes after presentation. Shortly after, propofol was initiated for post-intubation sedation at 10 mcg/kg/min. The remaining volume of ILE (125 mL) was then immediately infused over two hours at a rate of 0.013 mL/kg/min.\nApproximately 30 minutes after the initiation of ILE, the patient began to regain brainstem reflexes and eye movement, which progressed to head nods, then movement of his upper extremities. In addition, during that time period, his blood pressure and heart rate improved to within normal parameters. Sixty minutes later, the patient was able to communicate by writing down responses to questions. One hour after that, he had full recovery and was extubated. The patient recovered completely without any evidence of neurological sequelae and was discharged 30 hours after presentation.
An 8-year-old healthy male patient (30 kg weight and 130 cm height) with no history of epilepsy visited the dentist for tooth extraction. The patient had no known drug allergies. During his visit for extraction of deciduous second molar, the dentist injected 1.8 ml of 2% lignocaine (36 mg) with adrenaline (1:200,000) after prior aspiration at upper left maxillary vestibule with respect to deciduous second molar followed by 0.5 ml at left greater palantine nerve block. The total 46 mg lignocaine lasting over 2 min was administered. Immediately following the nerve block, the child presented with tonic-clonic convulsions. Patient was placed in supine position with elevated legs, and care was taken so as to protect from injuries. Injection diazepam was given. The vital signs and all laboratory investigations were normal. Neurological examination was unremarkable. MRI scan of the head and electroencephalogram were normal. There was no recurrence of seizures and the child was discharged after 1 day. Using Naranjo probability scale the relationship between the drug and the event was categorized as probable.