stellate ganglion block as an effective treatment for electrical strom

1. STELLATE
GANGLION BLOCK
FOR ELECTRICAL
STORM
ASWIN R.M.
07-03-2018

2. Cervical sympathetic block
■ Interruption of the sympathetic efferent fibers to the
upper extremity, head, and neck.
Diagnostic Prognostic Therapeutic

3. Cervical sympathetic block
■ Diagnostic :
– To determine if the pain is sympathetically
mediated or not.
■ Prognostic:
– To determine if neurolysis or surgical
sympathectomy could be beneficial

4. ANATOMY
 The cervical sympathetic chain -
superior, middle, & inferior cervical
ganglia
 80% population, the inferior
cervical ganglion is fused with the
first thoracic ganglion, forming the
CERVICOTHORACIC or the STELLATE
ganglion
chassaignac’s tubercle

5. ANATOMY
■ Oval shaped 2.5 x 1 x 0.5 cm
■ At the level of C7-T1,
anterior to the transverse
process of C7 & 1st rib &
longus coli muscle
■ Nearby structures
 the brachial plexus,
 spinal nerve roots,
 the prevertebral portion
of the vertebral artery
 Subclavian artery
 Cervical pleura

6. INDICATIONS
■ Most common indication - sympathetically mediated pain
■ Less commonly indications
– VT and electrical storm
– Hyperhidrosis
– Postherpetic neuralgia
– Ménière disease
– Accidental intra arterial injection of intravenous
medications,
– Frost bite
– Angina pectoris
– Hot flashes and
– Posttraumatic stress disorders.
– Raynauds syndrome

7. CONTRA INDICATIONS
– Coagulopathy,
– Pneumothorax,
– Glaucoma
– Atrioventricular block

8. STELLATE GANGLION BLOCK
TECHNIQUES
Surface
Landmark
Technique
Fluoroscopic
Technique
Ultrasound
guided
CT guided

9. SURFACE LANDMARK TECHNIQUE
■ C6 Anterior Approach
A successful block is seen by the onset of Horner syndrome with
affected extremity temperature increase greater than 3°F
(typically seen within 3 min)

10. SURFACE LANDMARK TECHNIQUE
Supine position with slight extension of the neck.
Head turned to the opposite side.
Cricoid cartilage is palpated to find the C6 level
Or more specifically, the C6 transverse process
(chassaignac’s tubercle)
Most individuals , tubercle ~ 3-4 cm cephalad to the
sternoclavicular joint at the medial border of the SCM

11. SURFACE LANDMARK
TECHNIQUE
The skin and subcutaneous tissue are pressed firmly
onto the tubercle
Needle advanced in AP direction retracting
Carotid to hit the tubercle
Needle withdrawn 2 mm to to come out of longus
colli muscle
Bupivacaine (0.125-0.5%) or Ropivacaine, 0.2%
1 mL test dose after negative suction 8-10 ml LA
injected with repeated negative aspiration
Monitored for 30 mins for evidence of blockade

12. FLOUROSCOPY GUIDED
■ Landmarks and patient positioning similar to blind
technique
■ Bony delineation better – fluoroscopy
■ Soft tissues including vascular structures -ultrasound
■ Both the C6 transverse process approach and the C7
anterior paratracheal approach can be done
■ Contrast to confirm appropriate needle placement
– Proper facial plane- local spread of contrast
between the tissue planes both cephalad and
caudad.
– Striated appearance – Intramuscular
– Intravascular injection -immediate dissipation of
dye

13. Flouroscopy guided

14. USS GUIDED
C6 transverse process approach
 Position & Needle insersion site Similar
 Carotid sheath and SCM muscle retracted laterally with
transducer
 Pressure is applied with the transducer
 reduce the distance between the skin and tubercle
 depresses dome of lung to reduce risk of
pneumothorax
The needle is inserted towards to the Chassaignac tubercle,
The needle is then withdrawn 1-2 mm to bring it out of the longus colli muscle while
still staying within the prevertebral fascia.
After negative aspiration, 1-2 mL of local anesthetic can be injected, and spread can
be visualized with ultrasound.
Once confirming that the injection was subfascial, the remaining local anesthetic can
be given.

15. C7 Anterior Approach
■ Nearly identical to the C6 approach.
■ Performed with USG or fluoroscopy - anatomical landmarks are more
difficult to identify because the C7 vertebra has only a vestigial
tubercle that is not readily palpable.
■ Risk of pneumothorax and vertebral artery injury is higher.
■ Advantages
– Needle is closer in proximity to ganglion
– A smaller volume of LA agent with more reliable and consistent
blockade.
– Particularily usefull - failed blockade at the c6 level.
■ An oblique C7 fluoroscopic approach targeting the junction between
the uncinate process and the vertebral body is described in an effort
to decrease those risks.
■ Lateral approach (USG Guided) also described

16. COMPLICATIONS
 Recurrent laryngeal
and Phrenic nerve block
 Brachial plexus block
 Pneumothorax
 Generalized seizure
 Total spinal anesthesia
 Severe hypertension
 Paratracheal
Hematoma

17. B/L BLOCK?
■ Better control of electrical storm
■ But not recommended since it causes severe
hypotension

18. ELECTRICAL STORM
■ 3 or more sustained episodes of
■ Ventricular tachycardia or ventricular fibrillation or
appropriate ICD shocks
■ Within 24 hours

20. ■ 52 year old male , old anteroseptal myocardial infarction
(MI) with CHB 2 years ago on VVI pacemaker
■ Recurrent VT requiring shocks and admission
■ Admitted for EP study & RF ablation
■ Developed recurrent episodes of VT
■ Ultrasound-guided left sympathetic ganglion block
■ Followed by surgical left cardiac sympathetic
denervation

21. THANK YOU