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High / Total Spinal

Cephalad spread of neuraxial local anesthetic causing apnea + cardiovascular collapse. Most common with epidural-to-subarachnoid migration in OB.

Recognition

  • •Rapidly ascending sensory + motor block
  • •Hypotension, bradycardia, dyspnea, hand weakness
  • •Loss of consciousness if cervical levels affected
  • •Apnea once phrenic (C3–C5) affected

Steps

  1. 1
    Call for help, 100% O₂, secure airway
    Most need intubation.
  2. 2
    Aggressive vasopressor + fluid
    Phenylephrine 100–200 mcg or epi 5–10 mcg titrated.
  3. 3
    Atropine 0.5–1 mg IV for bradycardia
    Sympathectomy unmasks vagal tone.
  4. 4
    Trendelenburg ONLY if airway already secured
    Otherwise risks aspiration; LA still moves cephalad with body position changes.
  5. 5
    Left uterine displacement if pregnant
  6. 6
    Maintain ventilation until block recedes (1–2 hours)

Drugs + doses

DrugDoseNote
Phenylephrine100–200 mcg IV q1 min, infusion 0.5–1 mcg/kg/min
Ephedrine5–10 mg IV (preferred for bradycardia + hypotension)
Epinephrine5–10 mcg IV titrated
Atropine0.5–1 mg IV

Pitfalls

  • !Always test-dose epidurals and aspirate before each top-up.
  • !Hypotension in OB high spinal → preserve uteroplacental flow with phenylephrine + LUD.

Sources

  • AANA Practice Considerations
  • Kinsella Anaesthesia 2020

Anatomy reference

Sourced reference images. 4 matches for "spinal cord meninges epidural".

fig-ch13_01_04
OpenStax · CC BY 4.0
fig-ch12_03_01
OpenStax · CC BY 4.0
fig-ch13_02_08
OpenStax · CC BY 4.0
fig-ch13_02_09
OpenStax · CC BY 4.0
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Education only — not a substitute for facility protocols, MOC certification, or clinical judgment. Always follow your institutional crisis algorithm and confirm doses against current package inserts.