Page 93 - Journal of Special Operations Medicine - Summer 2015

comfort. Widely prepare the skin over the anterior and right Figure 3 Ultrasound-guided, right-sided stellate ganglion
side of the neck with an alcohol and chlorhexidine solution, block (SGB). (A) Transducer positioning during a long-axis
and allow the solution to dry for 1 minute. Perform a clinical (in-plane) approach to the stellate ganglion. (B) Path of the
“time out” to confirm correct patient, correct procedure, and needle, going through the sternocleidomastoid, under the
correct side. internal jugular vein, through the longus capitus muscle just
ventral to the anterior tubercle of C6, and into the ventral
4. Ultrasound positioning: Apply a small amount, approxi- fascia of the longus coli muscle, laying immediately ventral to
mately 2 grams, of sterile ultrasound gel to the anterior neck the body of the C6 vertebra. (C) Long-axis needle approach,
at the level of the cricoid membrane. While seated on the with the needle tip in the ventral fascia of longus coli.
right side of the patient, place a cleaned and prepared high-
frequency linear transducer transverse at the level of the cricoid
membrane (i.e., sixth cervical vertebra, or C6, level). Raising
the procedure table to about the level of the provider’s chest
usually facilitates proper ergonomics. The depth of the ultra-
sound unit is set to visualize the ventral border of the C6 verte-
bral body (usually 4 cm in male patients). Identify the anterior A
tubercle of the C6 vertebra. The anterior tubercle of C6 has a
distinct peaked appearance, and the level can be confirmed by
being both at the level of the cricoid membrane and by it being
the most caudad anterior tubercle (which can be confirmed
with a short-axis slide in a caudad direction towards the clav-
icle). Identify key landmarks: the common carotid artery, inte-
rior jugular vein (facilitate viewing the entire internal jugular
vein by having the patient perform the Valsalva maneuver),
ventral portion of the C6 vertebral body, longus coli muscle
overlying the vertebral body, longus capitus muscle (usually)
overlying the anterior tubercle of C6. (Note: there is a high B
degree of anatomic variation in the anterior neck.) While in
this transverse view, use power Doppler or color Doppler to
scan and identify vascular structures, especially looking for
the well-documented anatomic variation of a vertebral artery
coursing anterior and medial to the anterior tubercle of C6.

5. Procedure: Refer to Figure 3. Envisioning a long-axis (or in-
plane) lateral approach, mentally ensure the needle can reach
the target area from the lateral neck. Place a skin wheal of
0.5mL buffered 1% lidocaine at the needle entry site. Using a
3.5-in long 22-gauge needle (or other appropriate needle), enter C
the neck with the needle in long axis to the ultrasound trans-
ducer (“in-plane” approach) going through sternocleidomas-
toid, continuing just ventral to the tip of the anterior tubercle of
C6, then continuing on until the needle tip has just penetrated
the ventral fascia of longus coli, just medial to the longus capi-
tus muscle and dorsal to the common carotid artery. The cervi-
cal sympathetic chain usually courses along the ventral fascia
of longus coli at this level, and it is sometimes, but not always,
clearly visible on ultrasound. Initially aspirate to check for no 6. Observation and monitoring: Observe and monitor the
blood in the hub of the needle, then slowly inject 7–8mL 0.5% patient for at least 30 minutes after completion of the injec-
ropivacaine (over 2 minutes in 0.5mL aliquots) to mitigate risk tion. Have the patient remain in the supine position (a pillow
associated with potential intravascular injection. The (anechoic) may be used at this time). The first sign of a successful block
injectate should flow just dorsal to the ventral fascia of longus will often be a sensation change on the right side of the face.
coli. There is significant anatomic variation in the anterior neck Once signs and symptoms of Horner’s syndrome are evident,
and slight variations of this description may be required. Let the the patient may sit reclined at a 20° angle for the remaining
patient know that they can talk during the injection if needed. observation period. These positions may facilitate produc-
Periodically ask the patient during the injection if they are do- tive anesthetic spread. Record the patient’s initial response to
ing well, and let the patient know that questioning them is just the injection, the time at which an obvious Horner’s response
another way to monitor how they are doing. It is absolutely was evident, and the quantitative score of the Horner’s syn-
critical to constantly keep the needle tip in view. If the needle drome. Approximately 20 minutes after the Horner’s response
tip cannot be visualized, stop the injection, reacquire needle tip is evident, inquire how the patient feels “mentally.” Usually
visualization, aspirate while checking for no blood in the hub of patients report some variation of feeling “relaxed, light, and
the needle, and only then restart the injection. calm.” An additional but optional step is to help the patient

Guidelines for Stellate Ganglion Block for PTSD Anxiety 83