Total Spinal

Question 1

What is a “total spinal?”

Answer 1

High or total spinal occurs with excessive cephalad spread of local anesthetic in the subarachnoid space. Increased incidence in obstetric population.

Question 2

What patient population has an increased incidence of total/high spinal?

Answer 2

Obstetric population

Question 3

What are the clinical features of a total spinal?

Answer 3

1. LOC
2. Respiratory depression
3. Hypotension
4. Dilated pupils

Question 4

What is the differential diagnosis when assessing a patient for high/total spinal?

Answer 4

1. Anxiety, panic attack
2. Drug overdose
3. Pulmonary embolus
4. Amniotic fluid embolus
5. Pulmonary edema
6. Seizures
7. Hypoglycemia

Question 5

What is the management of a total spinal?

Answer 5

1. Assess with repeated examination. High neuraxial blockade suggested with loss of ability to phonate or squeeze hand.
2. Supportive care (intubation, CPR, ventilation, left uterine displacement, IV fluids, pressors)
3. Caution with reverse trendelenburg. It will not prevent cephalad spread of local anesthetic and may lead to CV collapse due to venous pooling.

Question 6

Would you consider reverse trendelenburg position to protect/treat against high/total spinal?

Answer 6

Generally will fail to prevent cephalad spread of local anesthetic and may lead to CV collapse due to venous pooling.

Question 7

What physical exam findings prior to LOC of CV collapse, are indicative of high spinal?

Answer 7

Loss of ability to phonate

Loss of ability to squeeze hand