Intra-operative crises16 / 21
Bradycardic arrest under spinal anaesthesia22-year-old man, 78 kg, footballer, resting HR 48; very anxious
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Know this first
- Severe bradycardia after spinal is linked to baseline HR under 60 and male sex; younger age adds risk.
- Arrest under neuraxial block is more likely in young, healthy, conscious patients.
- A block to T1–T4 removes the cardioaccelerator fibres.
- In closed claims, delayed adrenaline gave uniformly poor neurological outcomes.
- Adrenaline 1 mg every 3–5 minutes; give it as soon as feasible in a non-shockable rhythm.
The patient
22-year-old man, 78 kg, footballer, resting HR 48; very anxious.
Drugs: none.
Ankle fracture fixation under spinal anaesthesia with heavy bupivacaine.
Vitals before the block: BP 124/70, HR 48, SpO2 99% on air, RR 14.
The examiner asks
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Consider
What are his risks under spinal anaesthesia?
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- A fit 22-year-old footballer with a resting HR of 48, for ankle fixation under spinal. Patient
- Baseline HR under 60 and male sex predict severe bradycardia; youth adds risk. Disease
- Sudden arrest under spinal happens most in young, healthy, awake patients like him.
- A block reaching T1–T4 cuts his cardioaccelerator fibres, leaving vagal tone unopposed.
- Low venous return can set off the Bezold–Jarisch reflex and a sudden slow heart. Stem trigger
Prepare
How do you prepare?
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- Atropine, ephedrine and adrenaline drawn up and labelled before the block. Crisis
- IV running, full monitoring, oxygen on, resuscitation trolley in the room.
- Light sedation only: oversedation featured in closed-claims arrests under spinal. Disease
- A fluid preload doesn't reliably prevent the hypotension, so I don't rely on it.
Plan
How do you manage him once the block is in?
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- Block height checked early and often; a high block means early treatment. Disease
- Ephedrine boluses for hypotension with a falling heart rate. Crisis
- Heart rate keeps falling: atropine 1 mg without waiting.
- No response: adrenaline next, early; delay worsened outcomes in spinal arrests.
- Anxiolysis by talking to him rather than heavy sedation. Patient
Crisis
Twenty minutes after the block, at T4, his HR drops from 46 to 30, then asystole; he is unresponsive. What do you do?
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- Adult arrest algorithm: asystole, non-shockable, in a young man with a high spinal. Crisis
- Call for help, start CPR now, surgeon stops.
- Adrenaline 1 mg IV at once, then every 3–5 minutes; it reverses his sympathectomy.
- Bag-mask 100% oxygen, then a tube; hypoxia may have triggered this. Airway
- Legs up and a fast fluid bolus to restore his venous return. Crisis
- Reversible causes in him: high block, low venous return, hypoxia.
- After ROSC: ICU, his family told, and a team debrief. After surgery
Fatal mistakes
- Escalating slowly through ephedrine and atropine while he deteriorates.
- Treating neuraxial bradycardia with fluids alone.
- Withholding adrenaline in a neuraxial arrest.
- Heavy sedation for his anxiety.
Checked against: Miller 10e · Barash 9e · AHA guidelines: adult advanced life support (2025)
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