LAST EVENT RECORD (Local Anesthetic Systemic Toxicity)
Hospital: ________________________ | Dept of Anesthesia	Form Code: F-19 | Version: ___ | Effective: ___ | PAGE 1 of 2

PATIENT IDENTIFIERS & EVENT CONTEXT
Name: _______________________________	MRN: _______________	DOB/Age: _________	Wt (kg): _____
Location: ☐ OR  ☐ NORA  ☐ PACU  ☐ Block Area Date: __________________ Time: ______________		Block / Infiltration Type: ______________________ Site / Side: ___________________________________

LOCAL ANESTHETIC(S) ADMINISTERED PRIOR TO EVENT
Drug	Conc (%)	Volume (mL)	Total mg	Time Last Injected

SYMPTOMS TIMELINE
Neurological Signs: ☐ Tinnitus    ☐ Metallic taste ☐ Perioral numbness    ☐ Agitation ☐ Seizure Time of Neuro Onset: ___________________	Cardiovascular Signs: ☐ Bradycardia    ☐ Hypotension ☐ Arrhythmia (type): _____________________ ☐ Cardiac Arrest Time of CV Onset: ____________________

IMMEDIATE ACTIONS

☐ Stop Local Anesthetic injection    Time: _______ ☐ Call for help / activate code    Time: _______ ☐ Airway support + 100% O₂    Time: _______ ☐ Seizure treatment    Time: _______      Drug/Dose: ________________________________ ☐ CPR started (if applicable)    Time: _______      Shocks (#): _______

LIPID DOSING QUICK BOX (20% LIPID EMULSION)
Under 70 kg: • Bolus: ~ 1.5 mL/kg over 2-3 min • Infusion: ~ 0.25 mL/kg/min	Over 70 kg: • Bolus: ~ 100 mL over 2-3 min • Infusion: ~ 250 mL over 15-20 min
* Follow ASRA LAST checklist and local resuscitation policy. Max lipid dose ~ 12 mL/kg.

LIPID THERAPY DOCUMENTATION
Bolus dose: _______ mL   at (Time): _______ Infusion started: _______ mL/min   at: _______	Repeat bolus? ☐ No    ☐ Yes    Dose / Time: __________________________________ Total lipid given: _______ mL

OTHER MEDS & INTERVENTIONS	OUTCOME
Epinephrine total: ________________________ Vasopressors: ___________________________ Antiarrhythmics: __________________________ Airway device used: _______________________	ROSC: ☐ Yes    ☐ No    Time: _______ Patient Stabilized: ☐ Yes    ☐ No Disposition: ☐ ICU    ☐ PACU    ☐ Ward ☐ Other: __________________________________

LAST EVENT RECORD (Local Anesthetic Systemic Toxicity)
Patient Name: _________________________ | MRN: _______________	Form Code: F-19 | PAGE 2 of 2

LABS & MONITORING SUMMARY (Post-Event)

ABG values: ________________________________________________________________________________ Electrolytes: _______________________________________________________________________________ ECG findings: _______________________________________________________________________________ Lactate: ____________________________________________________________________________________ ICU plan and monitoring duration: ____________________________________________________________ _____________________________________________________________________________________________

COMMUNICATION & REPORTING
Patient/family informed: ☐ Yes    ☐ No By (Name): ___________________________________ Incident report #: _____________________________	LAST kit restocked + seal replaced: ☐ Yes    ☐ No Hot debrief completed: ☐ Yes   ☐ No   Time: _____ Cold debrief planned: ☐ Yes   ☐ No   Date: _____

KEY LESSONS & ACTIONS (Debrief Summary)

SIGNATURES
Event Lead (Anesthesia Provider): Name: ___________________________________________ Sign: __________________________ Date/Time: _______	QI Reviewer / Department Lead: Name: ___________________________________________ Sign: __________________________ Date/Time: _______