Advance in EM
Ultrasound-Guided Stellate Ganglion Block in Refractory Ventricular Fibrillation
Dr KB Wong
Council Member, HKSEMS
Refractory ventricular fibrillation (RVF) is a complication of cardiac arrest defined as ventricular fibrillation (VF) that does not respond to three or more standard defibrillation attempts (1). These arrhythmias may be resistant to standard treatment, including CPR, defibrillation, epinephrine, and amiodarone (2). In the case of myocardial infarction, there was increased sympathetic nervous system activity, which decreases the arrhythmogenic threshold of the cardiac myocytes (3) Controlling the sympathetic nervous system can be done pharmacological by esmolol (4) or intervention called stellate ganglion block (5,6). Recently, a case report of a 65 years old man developed ROSC after 42 minutes of active cardiopulmonary resuscitation after stellate ganglion blockade, the patient was able to be discharged to subacute rehabilitation and experienced a full neurologic recovery. (7)
Ultrasonography-Guided SGB Procedure (8)
The structures were identified by ultrasonography (carotid artery, left internal jugular vein, longus coli muscle, vertebral artery, anterior scalene muscle, and brachial plexus). Local anesthetic such as 1% lidocaine was injected to the region of the stellate ganglion. After confirmation of proper placement, an additional 10 mL of local anesthetic is sufficient to create a field block and temporarily discontinue sympathetic activity. Extra care should be taken as there are numerous vascular structure around.
Image of stellate ganglion blockade guided by ultrasonography. The red arrow shows the path of the needle. CA indicates carotid artery; IJ, internal jugular vein; LC, longus colli muscle; SCM, sternocleidomastoid; SG, area of stellate ganglion; TH, thyroid; and VB, vertebral.
There were a few case series about the effectiveness of SGB in treating VF. Forty-nine patients (36 men, 13 women, mean age 57+/-10 years) who had ES associated with a recent myocardial infarction found that there was lower mortality in the patient group treated with blockage of sympathetic activity either by drug or intervention. (9). 20 consecutive patients with drug-refractory VT/VF who underwent bilateral SGB. The median number of episodes of VT/VF decreased from 4.5 in the 24 hours before SGB to 0 in the 24 hours after SGB. (10)
A systematic review of 38 patients from 23 studies in 2017 showed SGB resulted in a significant decrease in VA burden (12.4±8.8 vs. 1.04±2.12 episodes/day, p< 0.001) and number of external and ICD shocks (10.0±9.1 vs. 0.05±0.22 shocks/day, p< 0.01). Following SGB, 80.6% of patients survived to discharge.
A review of the complications about SGB was performed in 2018. There were 260 cases with adverse events between 1990-2018. SGB was also used in treating various chronic pain syndromes. (68.4%) patients had medication-related or systemic side effects, and 82 (31.5%) had procedure-related or local side effects. There was one report of death due to massive hematoma leading to airway obstruction. There was one case report of quadriplegia secondary to pyogenic cervical epidural abscess and discitis following an SGNB
In the setting of pulseless ventricular arrhythmia refractory to conventional measures, ultrasonographically guided regional nerve block of the sympathetic stellate ganglion may be potential lifesaving intervention. Further RCT is needed to determine its efficacy.
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