High / Total Spinal
Cephalad spread of neuraxial local anesthetic causing apnea + cardiovascular collapse. Most common with epidural-to-subarachnoid migration in OB.
⚡ Rehearsal mode
Walk the algorithm step by step
6 steps · click-through one at a time. Forces you to pre-read each action before moving on — the way you should rehearse the real thing.
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
- 1Call for help, 100% O₂, secure airwayMost need intubation.
- 2Aggressive vasopressor + fluidPhenylephrine 100–200 mcg or epi 5–10 mcg titrated.
- 3Atropine 0.5–1 mg IV for bradycardiaSympathectomy unmasks vagal tone.
- 4Trendelenburg ONLY if airway already securedOtherwise risks aspiration; LA still moves cephalad with body position changes.
- 5Left uterine displacement if pregnant
- 6Maintain ventilation until block recedes (1–2 hours)
Drugs + doses
| Drug | Dose | Note |
|---|---|---|
| Phenylephrine | 100–200 mcg IV q1 min, infusion 0.5–1 mcg/kg/min | |
| Ephedrine | 5–10 mg IV (preferred for bradycardia + hypotension) | |
| Epinephrine | 5–10 mcg IV titrated | |
| Atropine | 0.5–1 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
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Other crisis algorithms
- Malignant Hyperthermia (MH)
Hypermetabolic crisis triggered by volatile anesthetics or succinylcholine in genetically susceptible patients (RYR1, CACNA1S). Treat with dantrolene immediately.
- Perioperative Anaphylaxis
IgE-mediated (or pseudo-allergic) hemodynamic collapse from drug, latex, or transfusion exposure. Most common triggers in OR: NMBAs (rocuronium, succinylcholine), antibiotics, latex.
- Amniotic Fluid Embolism (AFE)
Rare, often fatal obstetric emergency — anaphylactoid syndrome of pregnancy. Sudden hemodynamic collapse, hypoxemia, and DIC during labor, delivery, or postpartum (within 30 min).
- LAST (Local Anesthetic Systemic Toxicity)
Cardiovascular and CNS toxicity from inadvertent IV injection or systemic absorption of local anesthetic. Bupivacaine highest cardiotoxicity. Ropivacaine + lidocaine slightly safer.
- Laryngospasm
Reflex closure of the vocal cords from light-anesthesia airway stimulation. Common in pediatrics, recent URI, and emergence. Untreated → hypoxia → bradycardia → arrest.
- Intraoperative Pulmonary Embolism
Sudden ↑PA pressure → RV failure → cardiovascular collapse. May be thrombus, fat (long-bone fracture, IM rod), gas (laparoscopy CO₂, sitting craniotomy), or amniotic.