A 42-year-old male patient is scheduled for arthroscopic repair of a rotator cuff tear. The surgeon requests a peripheral nerve block for postoperative analgesia. During the interscalene block procedure, the anesthesiologist inadvertently punctures the vertebral artery. The patient suddenly develops severe headache, vertigo, and loss of consciousness within 30 seconds. Which of the following is the most appropriate immediate management?

Explanation

## Vertebral Artery Puncture During Interscalene Block ### Pathophysiology Vertebral artery puncture during interscalene block can lead to rapid subarachnoid or intracranial injection of local anesthetic, causing: - Direct neurotoxicity - Seizures and loss of consciousness - Brainstem involvement (vertigo, respiratory depression) - Potential stroke from arterial dissection or thrombosis ### Immediate Management Algorithm ```mermaid flowchart TD A[Vertebral artery puncture suspected]:::urgent --> B[STOP procedure immediately]:::action B --> C[Position patient supine]:::action C --> D[Secure airway/prepare intubation]:::action D --> E[High-flow oxygen, IV access]:::action E --> F[Notify neurosurgery]:::action F --> G[Emergency CT/MRI brain]:::outcome G --> H[Supportive care + seizure prophylaxis]:::action ``` ### Key Management Steps **Key Point:** Vertebral artery puncture is a neurosurgical emergency requiring immediate cessation of the procedure and airway protection. 1. **Stop the block immediately** — do not inject further local anesthetic 2. **Position supine** — prevents further arterial injection 3. **Secure airway** — prepare for rapid sequence intubation; loss of consciousness is imminent 4. **Establish IV access** — for medications and fluid resuscitation 5. **Notify neurosurgery and ICU** — this requires intensive monitoring 6. **Emergency neuroimaging** — CT or MRI to assess for subarachnoid hemorrhage, infarction, or edema 7. **Seizure prophylaxis** — benzodiazepines (lorazepam) if not already intubated **Clinical Pearl:** The classic triad of vertebral artery injection is sudden loss of consciousness, seizures, and brainstem signs (respiratory depression, pupillary changes). Time is brain — neurosurgical consultation must be immediate. **High-Yield:** Do NOT apply direct pressure over the puncture site in the neck — this can worsen bleeding into deep neck spaces and compromise the airway further. The focus is airway protection and emergency imaging. ### Why This Complication Occurs The vertebral artery lies anterior to the interscalene groove at the C6 level. Medial needle advancement or patient anatomical variation increases risk. Ultrasound guidance reduces but does not eliminate this risk. [cite:Barash Clinical Anesthesia Ch 42]