COMPACT REVIEW OF LOWER LIMB BLOCKS FOR ANAESTHESIOLOGISTS

1. LOWER EXTRIMITY BLOCKS
PRESENTED BY : UNMESH[JR 1]
CORDINATED BY:
DR.SUCHITA JOSHI MADAM
DR.SNEHA MADAM
DEPARTMENT OF ANAESTHESIOLOGY,GMCH AURANGABAD.

2. INDICATIONS OF REGIONAL ANAESTHESIA:
• PATIENT REFUSAL FOR SPINAL
• SPINAL ANAESTHESIA CONTRAINDICATIONS: LOCAL AREA INFECTION,
SPINE DEFORMITY, COAGULATION DEFECTS
• Unlike upper limb extremity where all major nerves lie in the brachial
plexus, lower limb nerves are distributed all over

3. •Benefits of regional anaesthesia:
1. Reduction in stress response
2. Reduction in systemic analgesic requirements
3. Reduction in opioid related side effects
4. Excellent pain relief
5. Decreased pulmonary comlications
6. Haemodynamic stability

4. Lumbar and sacral plexus blocks
• Lumbar plexus: TKR, Anterior and posterior cruciate ligaments repair,
Patellar tendon repair
• Femoral nerve: TKR, Anterior cruciate ligament repair, femoral neck
fracture,saphenous vein stripping.
• Sciatic nerve: AK amputation, ankle joint surgeries,achilles tendon
repair
• Poplliteal nerve block: BK amputation, ankle and foot surgeries

5. DRUGS USED IN REGIONAL ANAESTHESIA:
Local anaestheic Usual conc Max dose of
plain solution
mg/kg
Max dose with
epinephrine
mg/kg
lidocaine 0.5 - 1 5 8
bupivacaine 0.125 -0.5 2 3
Levobupivacaine 0.125 -0.5 3 4
Ropivacaine 0.1 -0.75 3 Not
recommended

6. Contraindications:
• infection at the procedure site
• allergy to local anesthetics,
• indeterminate neuropathy

7. BLOCKS
LUMBAR COMPARTEMNT BLOCKS
• PSOAS COMPARTMENT BLOCK
• FASCIA ILIACA BLOCK
SACRAL COMPARTMENT BLOCKS
• SCIATIC NERVE BLOCK
• POPLITEAL NERVE BLOCK
• ANKLE BLOCK
INDIVIDUAL NERVE BLOCKS
• FEMORAL NERVE BLOCK
• LATERAL FEMORAL CUTANEOUS NERVE BLOCK
• OBTURATOR NERVE BLOCK
• 3 IN 1 NERVE BLOCK, INGUINAL PARAVASCULAR NERVE BLOCK
• SAPHENOUS NERVE BLOCK

8. Anatomy of lumber plexus
• Plexus is formed from L 1,2,3 AND 4 ,
• VENTRAL L 2,3,4 forms the obturator nerve, goes from medial border
of the psoas upto pelvic brim, passes from obturator foramina to
enter the thigh.
• DORSAL L 2,3 forms the LFCN, leaves psoas at L4,crosses iliacus, runs
towards ASIS, enters thigh 1 cm medial to ASIS
• DORSAL L 2,3,4 forms the femoral nerve, largest branch, comes from
the lateral border of the psoas, comes between the iliopsoas and runs
beneath the inguinal ligament

11. • The femoral nerve supplies the quadriceps muscle (knee extension),
the skin of the anteromedial thigh, and the medial aspect of the leg
below the knee and foot.
• The obturator nerve sends motor branches to the adductors of the
hip and a variable cutaneous area over the medial thigh or knee joint.
• The lateral femoral cutaneous, iliohypogastric, ilioinguinal, and
genitofemoral nerves are superficial sensory nerves.

13. Ilioinguinal block: indications
• Lower abdominal wall/inguinal region such as inguinal herniorrhaphy
• Analgesia after surgical procedures using a Pfannenstiel incision as
for cesarean section and abdominal hysterectomy.
• These blocks do not provide visceral anesthesia and thus cannot be
used as the sole anesthetic for procedures such as lower intra-
abdominal surgery. When used for inguinal herniorrhaphy, the sac
(containing peritoneum) must be infiltrated with local anesthetic by
the surgeon to complete anesthesia.

14. Surface landmarks:The point of needle insertion is marked 2 cm medial and 2 cm
superior from the anterior superior iliac spine.

18. • Total DRUG : 12 ML in fanlike positions.
• Accurate placement of LA both:
1. between the internal oblique and external oblique muscles,FIRST
loss of resistence
2. between the transversus abdominus and internal oblique
muscles,SECOND loss of resistence

19. TAP BLOCK
[TRANSVERSE ABDOMINUS PLANE BLOCK]

20. USES OF TAP BLOCK:
• Adjunct for postoperative pain control in abdominal, gynecologic , or
urologic surgery [ T6 to L1 distribution.]
• Surgical procedures include large bowel resection, caesarean delivery,
abdominal hysterectomy, open appendectomy, and laparoscopic
cholecystectomy.
• Bilateral TAP blocks can be used for midline incisions
• This technique is also useful for procedures in which epidural
analgesia is contraindicated

21. • transverse abdominis plane (TAP) block is a peripheral nerve block
designed to anesthetize the nerves supplying the anterior abdominal
wall (T6 to L1).
• Local anesthetic is then injected between the internal oblique and
transverse abdominis muscles just deep the fascial plane between
(the plane through which the sensory nerves pass

22. Lumbar plexus
• The patient is in the lateral decubitus position with a slight forward
tilt, the foot on the side to be blocked should be positioned over the
dependent leg so that twitches of the quadriceps muscle and patella
can be seen at 0.5 to 1 mA
• The anatomical landmarks are as follows:
1. Iliac crests (intercristal line)
2. Spinous processes (midline)
3. A point 3-4 cm lateral to the intersection of landmarks 1 and 2
(needle insertion point)
Time of onset : 20 to 30 minutes

24. LUMBAR PLEXUS BLOCK
• Lumbar plexus within the psoas sheath can be blocked by depositing the
drug after loss of resistance or a pop is felt on entering the compartment
• Position : prone
• technique: touhy needle is walked off the transverse process of L3
The correct compartment is reached 3 cm below the transverse process
Nerve stimulator is used to see quadriceps contraction.
The first sign of the onset of blockade is usually a loss of sensation in the
saphenous nerve territory [medial skin below the knee]
• Used for hip surgery
• Disadvantages: large volume of drug , positioning of the patient,
anatomical variation

25. • Skin to lumbar plexus distance corelates with BMI,
• MALE :61 to 101 mm
• Female : 57 to 93 mm
• Distance between posterior process of transverse process of L4 and
lumbar plexus is independent of gender and BMI: 18 mm
• Risk of retroperitoneal entry of needle is more if needle inserted 20
to 30 mm beyond the above said point
• Distance between medial border of psoas and spinal canal is 27 mm,
needle inserted 3 mm from the midline can result in spinal ,epidural
injection

28. Complications of lumbar plexus block
• Neuraxial spread, epidural and spinal spread of LA
• INTRAVASCULAR systemic toxicity,test dose and fractionated dose
should be administered, false negative test ose may be reported in
old age or patients on beta blockers.
• Hypotension form sympathetic chain block
• Block should be avoided in anticoagulated patients or pateints with
hemodynamic instability, may lead to hematoma
• Vascular puncture if gone deep into IVC

29. • Use small volume of drugs
• Use combination of 2 drugs to decrease toxicity of more toxic, long
acting LA

30. FEMORAL L2L3L4 NERVE BLOCK
• FEMORAL NERVE IS THE LARGEST BRANCH OF THE LUMBAR PLEXUS
• LOCATION: Deep to the inguinal ligament in the groove between the
iliopsoas
• In the inguinal region, it lies 1 cm lateral to femoral artery which is the
main landmark
• Superficial branch supplies the anterior surface of the thigh, sartorius and
pectinius
• Deep branch supplies the quadripceps and articular branches of hip and
the knee and continues as saphenous nerve.
• Femoral artery, vein and nerve are not in the same neurovascular plane
• Artery and vein are deep to fascia lata
• Nerve is deep to fasia iliaca and fascia lata, 2 popups are felt

31. INGUINAL LIGAMENT is
formed by transversalis
fascia and fasicia iliaca
Vascular fascia of the femoral artery
and vein: Funnel-shaped extension
of the transversalis fascia, forms a
different compartment from that of
the femoral nerve but contains the
femoral branch of the
genitofemoral nerve lateral to the
vessels.
Physical separation of the femoral
nerve from the vascular fascia
explains the lack of spread of a
“blind paravascular” injection of
local anesthetic toward the femoral
nerve.

34. Most favourable location to pierce the needle is the inguinal crease
because:
• Femoral nerve and artery are more superficial than at the level of
inguinal ligament
• Femoral nerve is wider
• Relationship of the nerve to the artery is prominent, in 80 percent of
the cases , nerve is lateral to the artery

35. • Drug volume : 15 TO 20 ml
• Onset : 15 to 20 min
• By nerve stimulator : give lateral to artery, 5 CM NEEDLE AT 45 DEGREE
CEPHALAD, see quadriceps twitch AT 2 to 3 cm[Patella snap, post motor
division of femoral nerve] at 0.5mA
• The first sign of onset of the blockade is a loss of sensation in the skin over
the medial aspect of the leg below the knee (saphenous nerve).
• By blind: 2 popups are felt using a short bevelled needle lateral to artery
• Uses: knee surgery, relief from pain of femur fractures, ACL reconstruction
• Other uses : as anaesthetic for muscle biopsy to rule out malignant
hyperthermia or for donor site for skin graft.

40. Complications of femoral block:
• If femoral artery is punctures, stop the procedure and keep pressure
of 3 minutes
• If vascular puncture appears, always redirect the needle laterally.
• Local anaesthesia toxicity

41. 3 in one block, FEMORAL +LATERAL
CUTANEOUS+OBTURATOR
• Blocks lateral cutaneous nerve of the thigh and obturator nerve supplying
the adductor muscles of the knee and articular branches of the hip and the
knee.
• Needle entry: same as femoral nerve block slightly above towards the
inguinal ligament
• Often describes as femoral block with overdosage as large volume of drug
is used and the fascial canal is filled upto the lumbar plexus
• 10 ml of drug for each nerve is used..upto 30 ml is given
• Cotinuous low dose 3 in one block can be given for postop pain
• LFC NERVE is blocked in 80 % cases and obturator in 30 % cases
• Reduces reuirement of postop opioids, used in THR

42. Lateral cutaneous nerve L1 L2 L3 thigh block
• Come from lumbar plexus
• Nerve passes lateral to the attachment of inguinal ligament 2 cm medial
and distal to ASIS, transverses laterally to psoas and courses anterolateral
to iliacus
• Block is given between sartorius and the inguinal ligament
• Field block with large volume in blind ,15 ml drug is deposited in the plane
between sartorius and tensor fascia lata, fan wise with 22 G 5 cm block
needle under the fascia lata 2 cm inferior and medial to ASIS. Space is
confirmed by popup of fascia lata or LOR.
• Pain from post op hip surgery is reduced by blocking T12 subcut across the
tip of the iliac crest

44. • Position: supine or lateral
• 2 cm medial and inferior to ASIS
• Tingling sensation is achieved in lateral part of the thigh
• NERVE STIMULATOR IS OF NO USE AS NERVE IS SENSORY
• USE: femur fracture and analgesia for donor of skin graft surgery
• Complications are less as very few vital structures present nearby

45. Usg-lfc nerve

46. Obturator block
indications:
• Indications:
1. hip joint pain
2. relief of adductor muscle spasm with hemi or paraplegia
3. urological surgery to suppress the obturator reflex during
transurethral resection of the lateral bladder wall
4. chronic pain states secondary to knee arthrosis or pelvic tumors
resistant to conventional analgesic approaches
• Volume: 15 to 20 ml

48. • Bony landmarks:
Anterior and superior iliac spine and pubic tubercle, inguinal ligament.
• Vascular landmarks:
femoral artery, femoral crease
• Muscular landmarks:
tendon of the long abductor muscle

49. Anatomical landmarks for the blockade of the obturator
nerve. 1. pubic tubercle; 2. Anterio-superior iliac spine; 3.
femoral artery; 4. tendon of the long adductor muscle

50. Obturator block
• Blocked along with femoral and sciatic nerve for complete anaesthesia of the
knee, sensory branches to hip, knee and medial thigh.
• Nerve exits the pelvis and enters medial thigh through obturator foramen lying
beneath the superior pubic ramus, 10 cm needle 1.5 cm inferior and 1.5 cm
lateral to the tubercle, needle is advanced until bone is hit, now directing laterally
and caudally, needle is advanced 4 cm until motor response is elicited at 0.5 mA
• Position: ABDUCT the leg and insert the needle between adductor tendons
inserting into the pubis, 10 cm block needle 1.5 cm inf and lateral to pubic
tubercle.
• The area of skin: posteromedial aspect of the knee.
• strength of the lower limb adductors relies 70% on the obturator nerve.
• reduction in the strength of the adductors of the thigh is the most reliable sign of
successful obturator nerve blockade.

51. Paravascular selective inguinal approach to obturator
nerve block; leg abduction.

52. If needle is directed towards ASIS, obturator foramen or bony margins of
the obturator foramen is hit…….now manipulate the tip and use a nerve
stimulus to see adduction.
Since we have to see adduction , original position of the leg before giving
block should be abducted.
But the main muscle of adduction, adductor magnus receives supply from
the sciatic nerve also, which may be misleading.

53. •Complications:
• Perforation of the bladder, rectum and spermatic cord
• Puncture of obturator vessels and hematoma

54. Sciatic nerve block L4 L5 S1 S2 S3
• Largest peripheral nerve in the body, 2 cm diameter
• Leaves the pelvis through sciatic notch , passes beneath the gluteus
maximus, to enter the thigh in between ischial tuberosity and GT
• 3 approaches: Posterior, classic or labat approach

55. Posterior approach:
1. Greater trochanter (Figure 1-6)
2. Posterior superior iliac spine (PSIS) (Figure 1-7)
3. Needle insertion point 4 cm distal to the midpoint between landmarks 1
and 2 (Figure 1-8)
• A line between the greater trochanter and the PSIS is drawn and divided in
half. Another line passing through the midpoint of this line and
perpendicular to it is extended 4 cm caudal and marked as the needle
insertion point.
• Volume: 10 ml
• Needle is 10 cm deep
• Gluteal muscles motor response is seen and foot inversion is observed.

56. Palpating greater
trochanter
Palpating PSIS

59. • LILTHOTOMY APPROACH:
• Easiest approach , in this nerve is relatively superficial is made taut
like a bowstring
• Entry point is same that is perpendicular to skin between Greater
Trochanter and Ischial Tuberosity
• NERVE IS 4 cm superficial in this approach in a groove between the
biceps femoris and semitendinosus

60. Subgluteal approach
• Easy landmarks and less tissue to transverse
line between greater trochanter and ischial tuberosity, from midpoint
of this line , second line is drawn perpendicular and extended caudally
4 cm. 10 cm insulated needle is inserted cephalad until foot plantar
flexion is elicitated.
• Volume : 25 ml

61. ANTERIOR APPROACH
• After leaving sciaitc notch , nerve goes behind LT behind femur, can be accesed medial to LT
• If giving along with femoral block, block the sciatic nerve first otherwise you cannot appreciate the anesthetised femoral nerve
then,
• POSITION: supine
• 1. ASIS TO PT Along inguinal ligament
• 2. parallel to first line transversing GT, IT Line
• 3. 2 lines are connected with a third line drawn from med 1/3 to lat 2/3 of first line at 90 degree and extended caudally to intersect
IT line.
• 15 CM NEEDLE at the insertion directed posteriorly,
• foot inversion is seen.
• If femur is hit, withdraw the needle and redirect after withdrawing 2 to 3 cm , patient is asked to rotate the leg internally and then
advanced the needle
• Volume: 25 ml
• Time to achieve block: 30 min
• ON USG : nerve is hyperechoic in fascial plane between adductors and gluteus muscle post to femur

63. Blocks around the knee, intraarticular knee
• Use in arthroscopy
• It is a day care procedure , patient needs to be discharged so
intraarticular injection over femoral block is preferred
• 20 ml is injected at the end of the procedure inside the joint cavity
• Infiltration around the instruments entry point is also used
• 1 mg morphine can be used inside joint cavity to block peripheral
opioid receptors

64. SAPHENOUS NERVE BLOCK/ADDUCTOR
CANAL BLOCK
• INDICATIONS : saphenous vein stripping, supplementation for medial
foot/ankle surgery in combination with sciatic nerve block, and
analgesia for knee surgery in combination with multimodal analgesia
• Goal : local anesthetic spread lateral to the femoral artery and deep
to the sartorius muscle or more distal, below the knee, adjacent to
the saphenous vein.
• Local anesthetic : 5–10 mL

66. Saphenous nerve block
• Most medial branch of femoral nerve and innervates skin over medial leg and ankle joint
• Given with sciatic block to complete analgesia
1. Transsartorial technique: proximal to knee deep to sartorius
Cross junction between sartorius, vastus medialis, adductor distal to adductor canal. Long
needle is inserted from medial to lateral or cephalad 10 ml of LA deposited within fascial
plane
2. Proximal saphenous technique: short block needle 2 cm distal to tibial tuberosity and
directed medially infiltrating 10 ml of LA as needle passes toward posterior aspect of leg.
Usg identifies saphenous vein near tibial tuberosity facilitating a perivascular technique
with infiltration about the vein.
3. Dorsal saphenous technique: medial malleolus is identified , 5 ml of LA is injected
Ina line running anteriorly around neck.

67. Simulated needle path (1) to reach the saphenous nerve
(SaN) at the level of the midthigh.
(B) Simulated needle path (1) and the distribution of the
local anesthetic (area shaded in blue) to anesthetize the
SaN at the midthigh level. SM, sartorius muscle; Vastus
M, vastus medialus muscle.

68. LEVELS AT WHICH
SAPHENOUS NERVE
BLOCKS ARE GIVEN

70. • saphenous nerve is a strictly sensory block, an injection of the local
anesthetic in the adductor canal can result in the partial motor block
of the vastus medialis.
• caution must be excercised when advising patients regarding the
safety of unsupported ambulation after proximal saphenous block.
• Being a sensory block, it s now preferred as quadriceps is spared and
patient can be ambulated early.

71. Popliteal fossa block
• Sciatic nerve bifurcates at the level of popliteal fossa into tibial nerve
and common peroneal nerve
• Fossa is a fat filled diamond shaped structure
• Tibial nerve is found at the apex lateral to the tibial artery
• Common peroneal nerve is found more laterally around the neck of
the fibula also known as the lathi charge nerve.
• Popliteal plus femoral block gives complete anaesthesia of the lower
leg
• Pns guides us to give better results

72. • Indications: ankle and foot surgery
• Landmarks: [intertendinous approach]popliteal fossa crease, tendons
of semimembranosus and semitendinosus
• Landmarks: [lateral approach]:popliteal fossa crease,vastus lateralis,
biceps femoris
• Nerve stimulation: foot twitch at 0.2 to 0.5 mA
• Volume: 30 to 40 ml

73. The sciatic nerve (1) is shown with its two divisions,
tibial (2) and common peroneal(3) nerves. The
common sciatic nerve is is seen between
semitendinosus (4), medially and biceps (5), laterally)
muscles enveloped by the thick epineural sheath (6).

75. point of needle insertion is marked at 7 cm above the
popliteal crease between tendons of semitendinosus
and semimembranosus muscles.

76. LATERAL APPROACH TO GIVE POPLITEAL
NERVE BLOCK:
insertion point (cross) 7 cm above the lateral femoral
epicondyle (circle) between the biceps femoris and vastus
lateralis muscles.
Lateral femoral epicondyle (circle) is easily palpated as a
prominence on the lateral aspect of the knee joint.

77. finger are pressed into a groove between the biceps
femoris (below) and vastus lateralis (above) muscles. Tip:
When these muscles prove difficult to palpated (rarely!!!),
the tendons can be accentuated by asking the patient to
patient.
The needle (100 mm long, insulated) is inserted in a
horizontal plane and advanced until the femur is
contacted.

78. After the femur is contacted, the needle is withdrawn to
the skin and redirected posteriorly at an angle of 30
degrees to the one at which the femur was contacted.

80. Response:
• First signs of the onset of blockade are usually reports by the patient’s of
inability to move their toes or that the foot “feels different.”
• Common peroneal nerve: dorsiflexion and eversion of foot
• Tibial nerve: plantar flexion and inversion of foot
• Tibial nerve response is more reliable
• small 1 mm movement of the needle results in a change in the motor
response from that of the popliteal nerve (plantar flexion of the foot) to
that of the common peroneal nerve (dorsiflexion of the foot). This indicates
needle placement at a level before the divergence of the sciatic nerve and
should be accepted as the most reliable sign of localization of the common
trunk of the sciatic nerve.
COMMON PERONEAL NERVE STIMULATION RESULTS IN DORSIFLEXION AND EVERSION OF THE FOOT.
STIMULATION OF THE TIBIAL NERVE RESULTS IN PLANTAR FLEXION AND INVERSION OF THE FOOT.
TIBIAL NERVE RESPONSE IS THE PREFERRED RESPONSE.

82. • Common peroneal nerve block , 5 ml drug given over the head of
fibula
• Saphenous nerve block at the level of knee, nerve is superficial, 10 ml
is given along medial epicondyle of tibia

83. ANKLE BLOCK:
• INDICATIONS: Foot and ankle surgery
• 2 deep nerves: posterior tibial and deep peroneal nerve
• 3 superficial: superficial peroneal,sural, saphenous nerve
• Volume: 5 ml per nerve
• ONSET: 10 to 25 minutes

84. Foot surgery
• Ankle block: 5 nerves
1. Tibial nerve: 5 ml is injected anterolateral to posterior tibial artery at the upper border
of medial malleolus.if the artery is not palpable, 10 ml is injectible at the same level
medial to achilles tendon. Sole of the foot is anaesthesized
2. Saphenous nerve: 5 ml subcut around saphenous vein anterior to medial malleolus.
Saphenous nerve supplies the medial malleolus and the medial edge and the dorsum
of the foot.
3. Deep peroneal nerve: 5 ml lateral and beneath the dorsalis pedis artery, if artery is not
palpable, give 1 cm lateral to EHL tendon
first two toes are anaesthesized
4.Superficial peroneal nerve:10 ml subcut anterior border of tibia and lateral malleolus.
Dorsal aspect of the foot is taken care of.
5. Sural nerve:5 ml between the lateral malleolus and achilles tendon
Sites: heel, lateral edge of the foot, posterolateral part of sole

85. Saphenous nerve above medial malleolus

86. Posterior tibial block
Palpating the pulse of the tibial artery posterior to the
medial malleolus.Posterior tibial nerve block is
accomplished by inserting the needle next to the
pulse.Needle is advanced until contact with bone is
established. At this point needle is withdrawn 2-3 mm
and 5 mL off LA is injected.

87. Deep peroneal nerve
Deep peroneal nerve is located lateral to the hallucis longus tendon (line)
Deep peroneal block: The needle is inserted just lateral to the hallucis longus tendon and
slowly advanced to contact the bone. Upon bone contact, the needle is withdrawn 2-3 mm,
and 5 mL of local anesthetic is injected.

88. Superficial peroneal nerve block is performed by
injecting local anesthetic in a circular fashion at the
level of the lateral malleolus and extending from
anterior to posterior.

89. Sural nerve block is accomplished by injecting local
anesthetic in a fanwise fashion subcutaneously and
below the fascia behind the lateral malleolus.

90. • Ankle block is one of the uncomfortable block procedures for
patients, it involves 5 separate needle insertions, and subcutaneous
injections to block the cutaneous nerves result in discomfort due to
the pressure distension of the skin and nerve endings.
• The foot is supplied by an abundance of nerve endings and is
exquisitely sensitive to needle injections. For these reasons, this block
requires significant premedication to make it acceptable to patients
• Begin this procedure with blocks of the two deep nerves because
subcutaneous injections for the superficial blocks often deform the
anatomy
• Avoid adrenaline in drug in major artery in presence of pvd

91. Side effects:
• Nerve injury due to anatomical variation
• Persons with peripheral neuropathy have a higher risk of prolonged or
sensorimotor blockade because of local ischemia from high pressure
injection or vasoconstrictors or neurotoxic effects of LA or direct
trauma to nerve tissue.
• Risk from intravascular drug delivery or perivascular penetration
• LA toxic reaction: seizure or cardiovascular collapse can occur
• Give CPR, lipid infusion and resuscitation

92. LAST
• Addition of 5 mcg of adrenaline to every ml of LA solution (1: 200000:
decreases systemic absorption of LA by 1/3 rd
Symptoms:
CNS: numbness of tongue,circumoral tissue,
restlessness,vertigo,tinnitus,slurred speech,muscle wasting,tonic clonic
seizures
CVS: hypotension, direct myocardial depression, decreased CO,
prolonged PR interval, arrythmias

93. Treatment of LAST
• CALL for help
• Airway management
• Seizure management: BZD > THIOPENTONE> PROPOFOL
• Amiodarone for arrhythmias
• ACLS if cardiac arrest
• Lipid emulsion: 1.5 mg/kg 20 % intralipid bolus followd by 0.25 ml/kg/min
infusion for 10 minutes
• If stability not attained repeat bolus,increase infusion to 0.5 ml/kg/min
• Max:10 ml/kg intralipid can be given

95. Thank you!!!