l病例报告患者，女，15岁，因慢性扁桃体炎在手术室行扁桃体摘除术。术前予2％地卡因表面麻醉。当时因喷雾器橡皮管破损，改用2％地卡因3ml，口含，患者不慎吞下，未及时告诉医护人员。2分钟后，患者面色苍白．出冷汗，全身抽搐，意识丧失，随即呼吸、心跳停止.立即行气管插管 l Case Report Patients, female, 15 years old, performed tonsillectomy in the operating room for chronic tonsillitis. Preoperative 2% dexamethasone topical anesthesia. At that time, due to damage to the rubber tube of the sprayer, 2ml of dextrose was used instead of 3ml of buccal mucosa, and the patient inadvertently swallowed it and did not tell medical staff in time. After 2 minutes, the patient was pale. Out of cold sweat, convulsions, loss of consciousness, then breathing, heartbeat stopped immediately tracheal intubation