After injecting a patient with lidocaine containing epinephrine, they develop sweating, nausea, and pallor. You check their heart rate and blood pressure which confirms your suspicion and you institute the appropriate treatment. Which of the following correctly labels the reaction with the associated pulse, blood pressure, and treatment?

A. Anaphylactic reaction. Heart rate low. Blood pressure low. Treatment: epinephrine

B. Anaphylactic reaction. Heart rate high. Blood pressure high. Treatment: epinephrine

C. Vasovagal reaction. Heart rate high. Blood pressure low. Treatment: Trendelenburg, cold compress, and avoid lidocaine in the future.

D. Vasovagal reaction. Heart rate low. Blood pressure low. Treatment: Trendelenburg, cold compress, reassure

E. Epinephrine reaction. Heart rate high. Blood pressure low. Treatment: Reassurance

E. Epinephrine reaction. Heart rate low. Blood pressure low. Treatment: Propranolol

Rationale: Injection reactions occur commonly in patients and particularly in young adults in my experience. Determining why patients are experiencing discomfort during anesthetic infiltration is important so that you can separate a normal response from an allergic response in an expedited fashion. 

Correct answer: D. Vasovagal reaction. Heart rate low. Blood pressure low. Treatment: Trendelenburg, cold compress, reassure

Out of the three reaction types, vasovagal reactions are the most common and patients generally require reassurance, a cold towel, and Trendelenburg positioning to rapidly improve their symptoms. Patients typically experience sweating and nausea. I have found that laying patients flat prior to starting the anesthesia infiltration helps reduce the rate of vasovagal reactions. There is no need to avoid lidocaine in the future as this is not an allergic reaction. 

Incorrect answers explained: 

For epinephrine reactions, patients have both high pulse and high blood pressure (which makes sense as it is a response to adrenaline). This reaction typically resolves in a few minutes without intervention however propranolol can also be used. Patients may experience palpitations, nervousness, and occasionally muscle tremors.  

For anaphylactic reactions, patients have a high pulse and low blood pressure resulting from peripheral vasodilation. Patients typically experience urticaria, angioedema, and respiratory distress. Immediate recognition is important as this is an emergent situation that will not self-resolve. Treatment with epinephrine, steroids, and airway management are critical. 

Additional reading at Dermatologic Surgery Chapter 12: Local Anesthesia, Regional Nerve Blocks, and Postoperative Pain Management