A patient undergoing spinal anaesthesia for elective hip replacement develops sudden hypotension (BP 80/50 mmHg) and bradycardia (HR 42 bpm) 10 minutes after intrathecal injection of hyperbaric bupivacaine 15 mg. The MOST appropriate initial management sequence is:

• A IV atropine 0.6 mg first for bradycardia, then vasopressors for hypotension
• B IV adrenaline 0.1 mg for both hypotension and bradycardia
• C Reversal of spinal with intrathecal saline flush
• D IV ephedrine 6 mg + rapid IV fluid bolus 500 mL + Trendelenburg position ✓

Explanation

Hypotension after spinal anaesthesia (sympathectomy-induced vasodilatation + reduced venous return) with bradycardia (Bezold-Jarisch reflex, high T4 sympathetic block) requires: (1) IV fluid bolus to restore preload, (2) vasopressor — ephedrine (mixed alpha+beta agonist) is historically preferred for spinal hypotension though phenylephrine is now preferred in obstetrics; (3) Trendelenburg to increase venous return. Atropine is added for symptomatic bradycardia (HR <50 + symptoms) but ephedrine's chronotropic and vasopressor properties address both. Adrenaline is reserved for severe refractory block or cardiac arrest.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.