High Spinal / Total Spinal Emergency

Algorithm Steps

1. ▶

   Start

   High/Total Spinal Suspected

   Signs of excessive neuraxial block spread

   1. ●

      Action

      Recognition

      Clinical signs of high spinal block

      • EARLY SIGNS:
      • Rapid ascending sensory level (T4 or higher)
      • Difficulty breathing / dyspnea
      • Arm weakness or tingling
      • Hypotension (significant drop from baseline)
      • SEVERE SIGNS:
      • Inability to speak / weak voice
      • Apnea / respiratory arrest
      • Bradycardia
      • Loss of consciousness
      • Pupil dilation (if very high)
      1. ●

         Action

         Call for Help Immediately

         This is an emergency

         • Call for senior anesthesia help
         • Call for resuscitation team if needed
         • Alert OB team if obstetric patient
         • Assign roles for airway, drugs, documentation
         1. ●

            Action

            Airway and Breathing

            Immediate respiratory support

            • 100% oxygen via face mask
            • Support ventilation - BVM if weak effort
            • Reassure patient (if conscious) - very frightening
            • IF APNEIC OR NEAR-APNEIC:
            • Bag-mask ventilate
            • Prepare for intubation
            • Consider cricoid pressure (aspiration risk if pregnant)
            • Reduced dose induction agent needed (if GA)
            • Patient may already be anesthetized
            1. ●

               Action

               Circulation Support

               Treat hypotension and bradycardia aggressively

               • POSITIONING:
               • Left lateral tilt 15° (if pregnant)
               • Head down may worsen block spread
               • FLUIDS:
               • Rapid IV crystalloid bolus 500-1000 mL
               • VASOPRESSORS:
               • Phenylephrine 50-100 mcg IV boluses
               • OR Ephedrine 6-12 mg IV boluses
               • Repeat every 1-2 min as needed
               • Consider infusion if refractory
               • BRADYCARDIA:
               • Atropine 0.6-1.2 mg IV
               • Epinephrine 10-100 mcg IV if severe
               1. ◆

                  Decision

                  Patient Condition?

                  Assess response to initial treatment

                  1. ●

                     Action

                     Supportive Care

                     For stable patients breathing adequately

                     • Continuous verbal reassurance
                     • 100% O2
                     • Frequent vitals monitoring
                     • Continue vasopressor as needed
                     • Keep patient warm
                     • Document block level serially
                     1. ●

                        Action

                        Ongoing Monitoring

                        Block will regress over time

                        • Continuous pulse oximetry and capnography
                        • BP every 1-2 min initially
                        • Serial sensory level assessment
                        • Motor function recovery
                        • EXPECT:
                        • Block regression over 1-4 hours
                        • Motor before sensory recovery
                        • May need prolonged ventilatory support
                        1. ●

                           Action

                           Post-Event Care

                           Documentation and follow-up

                           • Document thoroughly
                           • Patient debrief when recovered
                           • Consider ICU if prolonged event
                           • Incident reporting
                           • Root cause analysis
                           • Consider future anesthetic implications
                           1. ✓

                              Outcome

                              Patient Stabilized

                              Block regressed, full recovery expected

                  2. ⚠

                     Warning

                     ⚠️ Intubation Required

                     For apnea or inadequate ventilation

                     • Reduced dose induction (patient already obtunded)
                     • Consider ketamine (maintains BP)
                     • Succinylcholine or rocuronium
                     • Prepare for difficult airway in obstetric patient
                     • POST-INTUBATION:
                     • Continue vasopressor support
                     • Convert to GA if needed for surgery
                     • Plan for delayed emergence
                  3. ⚠

                     Warning

                     ⚠️ Cardiac Arrest

                     Start CPR immediately

                     • Standard CPR algorithm
                     • Epinephrine 1 mg IV every 3-5 min
                     • Continue chest compressions
                     • Intubate urgently
                     • OBSTETRIC PATIENT:
                     • Perimortem C-section if >4 min CPR
                     • Continue left uterine displacement during CPR