High/Total Spinal Suspected
Signs of excessive neuraxial block spread
All Pathways
AnesthesiologyEmergency
High Spinal / Total Spinal Emergency
High Spinal / Total Spinal Emergency: High/Total Spinal Suspected → Recognition → Call for Help Immediately → Airway and Breathing → Circulation Support.
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action 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)
03Action 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
04Action 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
05Action 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
06Decision Patient Condition?
Assess response to initial treatment
07Action 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
08Action 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
09Action 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
10Outcome Patient Stabilized
Block regressed, full recovery expected
11Warning ⚠️ 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
- Path rejoins step 08Shared downstream outcome
12Warning ⚠️ 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
- Path rejoins step 08Shared downstream outcome
Guideline Source
Management of Severe Local Anaesthetic Toxicity and High Spinal Block - OAA/AAGBI
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Obstetric modifications (left tilt) specific to pregnant patients
- Local protocols may vary
- Requires skilled airway management
- May progress rapidly - early intervention critical
Applicable Regions
USEUUKglobal
UK: Based on OAA/AAGBI guidelines
US: Compatible with ASA/SOAP recommendations
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the High Spinal / Total Spinal Emergency?
The High Spinal / Total Spinal Emergency is a emergency clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on Management of Severe Local Anaesthetic Toxicity and High Spinal Block - OAA/AAGBI.
What guideline is the High Spinal / Total Spinal Emergency based on?
This algorithm is based on Management of Severe Local Anaesthetic Toxicity and High Spinal Block - OAA/AAGBI (DOI: 10.1093/bja/aey293).
What are the limitations of the High Spinal / Total Spinal Emergency?
Known limitations include: Obstetric modifications (left tilt) specific to pregnant patients; Local protocols may vary; Requires skilled airway management; May progress rapidly - early intervention critical. Individual patient factors may require deviation from these recommendations.
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