Background and Aims Local anesthetic systemic toxicity (LAST) is a rare but potentially life-threatening adverse event that occurs after local anesthetic administration through different routes¹. This case intends to highlight the importance of bidirectional communication in the operating room (OR) and identification of warning signs and symptoms of LAST.

Methods A healthy 22-year-old female (weight 56 Kg, height 159cm), with a type III odontoid fracture due to a vehicle roll over was brought to the OR for a halo-vest placement. The procedure was executed under monitored anesthesia care, with the use of local anesthetic (LA) alone, as requested by the surgical team, allowing neurological examination throughout its execution. 2% lidocaine without adrenaline was administered subcutaneously in the frontotemporal region for pin insertion.

Results After 40 minutes, the patient became agitated, complained of blurred vision, metallic taste, and developed supra-ventricular tachycardia. When questioned, the surgical team revealed that 30 mL of lidocaine had been administered. The anesthesia team presumed the complaints were due to LAST and Institutional protocol was implemented. It includes antiepileptic therapy, hemodynamic and ventilatory support and lipid emulsion therapy. Upon termination, the patient was transferred to a post-anesthetic-care-unit and was discharged 24h later without any further complications.

Conclusions Systemic toxicity can be life threatening and rapid identification is key to prevent mortality. Although subcutaneous administration is less prone to toxicity, multiple injections in the scalp, witch is a highly vascularized area, cause a rapid absorption². Bidirectional team communication in the OR is essential for complication prevention, intraoperative differential diagnosis and systematic approach in such critical events.