<p begin="00:00:09.402" end="00:00:11.659" style="s2">- Today I'm going to demonstrate<br />the stellate ganglion block</p>
<p begin="00:00:11.659" end="00:00:13.495" style="s2">performed under ultrasound guidance.</p>
<p begin="00:00:13.495" end="00:00:15.962" style="s2">Traditionally this block<br />was performed blindly,</p>
<p begin="00:00:15.962" end="00:00:18.270" style="s2">without the use of any imaging modality.</p>
<p begin="00:00:18.270" end="00:00:20.964" style="s2">Currently thoracoscopy<br />is a preferred method,</p>
<p begin="00:00:20.964" end="00:00:24.667" style="s2">however utilizing ultrasound<br />such as this M Turbo system</p>
<p begin="00:00:24.667" end="00:00:28.071" style="s2">utilizing the HFL 50 linear probe,</p>
<p begin="00:00:28.071" end="00:00:30.052" style="s2">this can be done with less radiation</p>
<p begin="00:00:30.052" end="00:00:31.672" style="s2">and avoidance of vascular structures</p>
<p begin="00:00:31.672" end="00:00:33.446" style="s2">that might not otherwise be seen</p>
<p begin="00:00:33.446" end="00:00:35.143" style="s2">under thoracoscopic guidance.</p>
<p begin="00:00:35.143" end="00:00:39.310" style="s2">The C6 transverse process,<br />Chassaignac's tubercle,</p>
<p begin="00:00:40.457" end="00:00:43.574" style="s2">immediately inferior is the C7 body</p>
<p begin="00:00:43.574" end="00:00:45.491" style="s2">and transverse process.</p>
<p begin="00:00:46.380" end="00:00:49.120" style="s2">The probe is placed in a<br />transverse orientation,</p>
<p begin="00:00:49.120" end="00:00:53.287" style="s2">clearly identifying and<br />avoiding the vertebral artery.</p>
<p begin="00:00:54.506" end="00:00:57.084" style="s2">And the needle coming in contact with</p>
<p begin="00:00:57.084" end="00:00:59.251" style="s2">the C7 transverse process.</p>
<p begin="00:01:01.288" end="00:01:03.217" style="s2">To perform this particular block,</p>
<p begin="00:01:03.217" end="00:01:05.682" style="s2">the following equipment is necessary.</p>
<p begin="00:01:05.682" end="00:01:08.398" style="s2">The chlorhexidine prep,</p>
<p begin="00:01:08.398" end="00:01:09.957" style="s2">one percent buffered lidocaine</p>
<p begin="00:01:09.957" end="00:01:13.862" style="s2">with a one and one half<br />inch 27 gauge needle,</p>
<p begin="00:01:13.862" end="00:01:18.297" style="s2">a 25 gauge three and one<br />half inch spinal needle,</p>
<p begin="00:01:18.297" end="00:01:21.172" style="s2">a 10 cc syringe that<br />will contain seven ccs</p>
<p begin="00:01:21.172" end="00:01:23.851" style="s2">of one percent lidocaine with epinephrine,</p>
<p begin="00:01:23.851" end="00:01:27.719" style="s2">or quarter percent<br />bupivacaine with epinephrine.</p>
<p begin="00:01:27.719" end="00:01:29.722" style="s2">The procedure is<br />performed with the patient</p>
<p begin="00:01:29.722" end="00:01:32.412" style="s2">in the supine position, with the chin up</p>
<p begin="00:01:32.412" end="00:01:35.728" style="s2">and the following anatomic<br />structures are identified.</p>
<p begin="00:01:35.728" end="00:01:39.358" style="s2">The thyroid cartilage, the<br />cricoid cartilage, and then,</p>
<p begin="00:01:39.358" end="00:01:42.176" style="s2">the finger is placed in the<br />groove next to the trachea,</p>
<p begin="00:01:42.176" end="00:01:46.480" style="s2">and pressure applied until<br />a bony protuberance is felt.</p>
<p begin="00:01:46.480" end="00:01:48.317" style="s2">This is Chassaignac's tubercle or</p>
<p begin="00:01:48.317" end="00:01:51.128" style="s2">the transverse process of C6.</p>
<p begin="00:01:51.128" end="00:01:53.099" style="s2">Currently, the use of thoracoscopy</p>
<p begin="00:01:53.099" end="00:01:55.903" style="s2">indicates use at the C7 level.</p>
<p begin="00:01:55.903" end="00:01:57.658" style="s2">The reason for this is to provide</p>
<p begin="00:01:57.658" end="00:02:00.853" style="s2">better sympathetic blockade<br />while avoiding some</p>
<p begin="00:02:00.853" end="00:02:03.716" style="s2">of the common side effects<br />such as Horner's syndrome,</p>
<p begin="00:02:03.716" end="00:02:07.382" style="s2">as well as recurrent<br />pharyngeal nerve paralysis.</p>
<p begin="00:02:07.382" end="00:02:10.301" style="s2">In this case, the HFL 50<br />probe will be utilized.</p>
<p begin="00:02:10.301" end="00:02:14.213" style="s2">It provides a very high<br />definition, high resolution view</p>
<p begin="00:02:14.213" end="00:02:16.796" style="s2">of the subcutaneous structures.</p>
<p begin="00:02:19.814" end="00:02:23.647" style="s2">Gel is placed at the<br />formerly marked C6 level.</p>
<p begin="00:02:25.278" end="00:02:29.549" style="s2">And the HFL 50 probe is placed on the skin</p>
<p begin="00:02:29.549" end="00:02:31.882" style="s2">in a transverse arrangement.</p>
<p begin="00:02:34.594" end="00:02:37.150" style="s2">The initial view is of<br />the cricoid cartilage,</p>
<p begin="00:02:37.150" end="00:02:40.861" style="s2">and then the probe is<br />moved slightly cephalad</p>
<p begin="00:02:40.861" end="00:02:44.116" style="s2">and then rotated slightly outward.</p>
<p begin="00:02:44.116" end="00:02:48.060" style="s2">At this point the thyroid as<br />well as the carotid artery</p>
<p begin="00:02:48.060" end="00:02:50.833" style="s2">and Chassaignac's tubercle<br />are clearly visible</p>
<p begin="00:02:50.833" end="00:02:54.786" style="s2">as the hump located immediately<br />in the center of the screen.</p>
<p begin="00:02:54.786" end="00:02:57.203" style="s2">Since this is the C6 tubercle,</p>
<p begin="00:02:57.203" end="00:03:00.856" style="s2">we will move slightly<br />interior until it flattens out</p>
<p begin="00:03:00.856" end="00:03:04.439" style="s2">and this becomes the<br />C7 transverse process.</p>
<p begin="00:03:05.932" end="00:03:10.667" style="s2">It's important to note<br />at this point to utilize</p>
<p begin="00:03:10.667" end="00:03:13.426" style="s2">the color flow Doppler which will indicate</p>
<p begin="00:03:13.426" end="00:03:16.941" style="s2">vascular structures such as<br />perforating thyroidal arteries</p>
<p begin="00:03:16.941" end="00:03:19.859" style="s2">that are not to be violated,</p>
<p begin="00:03:19.859" end="00:03:21.930" style="s2">as well as the carotid artery,</p>
<p begin="00:03:21.930" end="00:03:24.533" style="s2">and the vertebral artery more laterally.</p>
<p begin="00:03:24.533" end="00:03:28.700" style="s2">The structure of interest<br />is the longus colli muscle.</p>
<p begin="00:03:29.590" end="00:03:31.727" style="s2">At this point, local anesthetic</p>
<p begin="00:03:31.727" end="00:03:35.144" style="s2">one percent lidocaine buffer is injected,</p>
<p begin="00:03:36.173" end="00:03:40.233" style="s2">and a 25 gauge three<br />and a half inch needle</p>
<p begin="00:03:40.233" end="00:03:44.400" style="s2">is advanced through this track<br />to contact the oss at C7.</p>
<p begin="00:03:48.349" end="00:03:51.806" style="s2">The needle is backed off<br />slightly and then the injection</p>
<p begin="00:03:51.806" end="00:03:55.787" style="s2">of local anesthetic,<br />preferably epinephrine</p>
<p begin="00:03:55.787" end="00:03:58.541" style="s2">containing one percent lidocaine,</p>
<p begin="00:03:58.541" end="00:04:02.229" style="s2">six to seven ccs is gently<br />and slowly injected.</p>
<p begin="00:04:02.229" end="00:04:06.922" style="s2">At this point, the probe<br />is removed, the skin wiped</p>
<p begin="00:04:06.922" end="00:04:10.755" style="s2">and cleaned, and if<br />needed, a band aid placed</p>
<p begin="00:04:10.755" end="00:04:12.591" style="s2">over the small puncture site.</p>
<p begin="00:04:12.591" end="00:04:15.199" style="s2">This successfully concludes<br />a stellate ganglion block</p>
<p begin="00:04:15.199" end="00:04:18.199" style="s2">performed under ultrasound guidance.</p>