(142) From Root Canal to CCU: A Perplexing Case of Cardiac Arrest Following Local Anesthetic

Introduction: Cardiac arrest during routine dental procedures is extremely rare. Local anesthetic systemic toxicity (LAST) is an uncommon complication that can lead to neurological and cardiovascular disturbances. This case report presents a patient who experienced cardiac arrest during a routine root canal procedure.

Description: The patient, with a history of hypertension, hyperlipidemia, and mitral valve prolapse, experienced cardiac arrest ten minutes after receiving articaine with epinephrine. She exhibited dilated pupils, and seizure-like activity, and became unresponsive. CPR was initiated, and she experienced multiple cardiac rhythms (PEA, torsades, and ventricular fibrillation). The total downtime was approximately one hour. Upon hospital admission, the patient was in cardiogenic shock, requiring intubation and vasopressor support. An echocardiogram revealed a reduced ejection fraction (30%, down from 55-60% baseline). Left heart catheterization showed elevated filling pressures and single-vessel coronary artery disease in the apical LAD. Treatment included an intra-aortic balloon pump (IABP) and dobutamine. The patient developed atrial fibrillation, managed with amiodarone and anticoagulation. As her condition improved, the IABP was removed, pressors were weaned off, and she was extubated. Post-extubation, the patient exhibited left-sided gaze neglect. Brain imaging revealed infarcts in various regions. Her ejection fraction improved, and a cardiac MRI showed mitral annular disjunction, which may predispose to ventricular arrhythmias. The etiology of the initial arrest remains unclear, with possibilities including stress-induced cardiomyopathy, acute coronary syndrome, or LAST. The patient was discharged with plans for guideline-directed medical therapy. An implantable cardioverter-defibrillator was placed, and neurological rehabilitation was scheduled.

Discussion: This case illustrates a rare incident of cardiac arrest during routine dental work and complex interplay between heart disease, arrhythmias, and thromboembolism. Improved LVEF suggests some recovery and brain infarct suggests embolic complications likely due to recent arrest and CPR. It emphasizes vigilance for cardiac events in dental settings, the need for broad diagnostics, and the value of prompt medical response.