# Situation: A 66-year-old man weighing 72 kg undergoes open repair of a right inguinal hernia under spinal anesthesia. He had a right total hip replacement 5 years ago and has a healed surgical scar on the left buttock. Ten minutes after the spinal injection, while the table is tilted head-down, he says his hands are tingling and weak and he cannot take a deep breath. His blood pressure is 84/48 mmHg (132/80 mmHg before the block) and his heart rate is 48/min. Estimated blood loss is 20 mL. He has no perioral numbness or ringing in the ears. Which problem do these findings MOST likely indicate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629771  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 66-year-old man weighing 72 kg undergoes open repair of a right inguinal hernia under spinal anesthesia. He had a right total hip replacement 5 years ago and has a healed surgical scar on the left buttock.

Ten minutes after the spinal injection, while the table is tilted head-down, he says his hands are tingling and weak and he cannot take a deep breath. His blood pressure is 84/48 mmHg (132/80 mmHg before the block) and his heart rate is 48/min. Estimated blood loss is 20 mL. He has no perioral numbness or ringing in the ears. Which problem do these findings MOST likely indicate?

## 보기

1. Hypovolemia from surgical bleeding
2. Expected sympathetic block from the spinal
3. High spinal block **✔ 정답**
4. Local anesthetic systemic toxicity

**정답: 3**

## 해설

Some fall in blood pressure is expected after a spinal because sympathetic nerves are blocked, but hand tingling and weakness with difficulty breathing mean the anesthetic has spread up to the cervical and upper thoracic nerves (helped here by the head-down tilt). That is a high spinal block, which needs airway and ventilation support, fluids, vasopressors, and atropine.

## 심화 해설

Reading the findings: a block that has risen too high
A spinal anesthetic for inguinal hernia repair is meant to block the lower thoracic, lumbar, and sacral nerves. Ten minutes after the injection, with the table tilted head-down, the client reports tingling and weakness of the hands and cannot take a deep breath. His blood pressure has fallen from 132/80 to 84/48 mmHg and his heart rate is 48/min. Arm symptoms and difficulty breathing mean the anesthetic has spread to the cervical and upper thoracic nerves: this is a high spinal block. The head-down tilt helped a heavier-than-CSF anesthetic flow toward the head.

Mechanism of the signs
Hand symptoms appear when the block reaches the lower cervical segments (C6 to C8). Breathing becomes difficult as intercostal muscles are blocked, and the danger grows as the block approaches C3 to C5, which supply the diaphragm through the phrenic nerve. Severe hypotension follows the widespread loss of sympathetic tone, and bradycardia occurs when the block reaches the cardioaccelerator fibers at T1 to T4, leaving vagal tone unopposed. This combination of hypotension and a slow heart rate is the hallmark of an extensive sympathetic block.

| Option | Typical picture | Fits this client? |
| --- | --- | --- |
| Hypovolemia from bleeding | Hypotension with tachycardia; significant blood loss | No: loss 20 mL, heart rate 48 |
| Expected spinal effect | Mild hypotension; arms and breathing normal | No: arms and breathing affected |
| High spinal block | Hypotension, bradycardia, arm weakness, dyspnea | Yes |
| Local anesthetic toxicity | Perioral numbness, metallic taste, tinnitus, seizures | No: none of these |

Why the other options do not fit
Hypovolemia is unlikely with an estimated blood loss of only 20 mL, and it produces a fast heart rate, not 48/min. Some fall in blood pressure is expected after any spinal because sympathetic fibers are blocked, but a usual block for this surgery leaves the arms and breathing unaffected. Local anesthetic systemic toxicity begins with central nervous system signs such as perioral numbness, metallic taste, and ringing in the ears, which the stem specifically denies.

Watch out! A high spinal can progress to a total spinal, with apnea and loss of consciousness, within minutes. The nurse stays with the client, alerts the anesthesiologist, and prepares for airway and ventilation support, oxygen, IV fluids, vasopressors, and atropine for the bradycardia.

Exam takeaway
Key point! After spinal anesthesia, upper-limb symptoms or breathlessness with hypotension and bradycardia mean the block is too high. The priority is airway and breathing support together with treatment of hypotension and bradycardia. Check the level of the block, the position of the table, and the time since injection when interpreting new symptoms.

## 임상 시나리오

High Spinal BlockSpinal anesthesia spreading above the intended level
Hand tingling and weakness with difficulty breathing after a spinal mean the block has reached the cervical and upper thoracic nerves. A head-down tilt can help the drug spread upward.

Widespread sympathetic block causes hypotension, and block of the cardioaccelerator fibers at T1 to T4 causes bradycardia, here 84/48 mmHg and 48/min.

Support airway and ventilation, give oxygen, fluids, vasopressors, and atropine as ordered, and keep the anesthesiologist at the bedside.

CautionA block reaching C3 to C5 can stop diaphragmatic breathing; be ready for bag-mask ventilation and intubation.

## 핵심 개념

- **High spinal block** — Spread of spinal anesthetic above the intended level, causing arm weakness, breathing difficulty, hypotension, and bradycardia.
- **Sympathetic block** — Loss of sympathetic nerve tone from spinal anesthesia, causing vasodilation and a fall in blood pressure.
- **Cardioaccelerator fibers** — Sympathetic nerves from T1 to T4 that speed the heart; blocking them causes bradycardia.
- **Local anesthetic systemic toxicity** — A reaction to high blood levels of local anesthetic, starting with perioral numbness and tinnitus and progressing to seizures.

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