Ans + stellate ganglion block

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A brief summary on formation and functioning of Autonomic Nervous System, with a general idea on Stellate Ganglion Block.

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Ans + stellate ganglion block

  1. 1. TheSympatheticNervous SystemOrganisation and ClinicalsMod. Dr. Avanish Bhardwaj
  2. 2. Organization of The Nervous SystemCentral Nervous System Peripheral Nervous SystemSensory- Somatic NervousSystemAutonomic Nervous SystemSympathetic Parasympathetic
  3. 3. The Autonomic Nervous System andVisceral Sensory Neurons The Autonomic Nervous System It is responsible for monitoring conditions in theinternal environment and bringing aboutappropriate changes in them. Innervates smooth muscle, cardiac muscle, andglands Regulates visceral functions Heart rate, blood pressure, digestion, urination
  4. 4. The Autonomic Nervous System and VisceralSensory NeuronsFigure 1
  5. 5. Comparison of Autonomic andSomatic Motor Systems Somatic motorsystem One motor neuronextends from theCNS to skeletalmuscle Axons are wellmyelinated, conductimpulses rapidly Autonomic nervoussystem Chain of two motorneurons Preganglionicneuron Postganglionicneuron Conduction is slowerdue to thinly orunmyelinated axons
  6. 6. Autonomic and Somatic MotorSystems
  7. 7. Divisions of the Autonomic NervousSystem Sympathetic and parasympathetic divisions Innervate mostly the same structures, but causeopposite effects Sympathetic – “fight, flight, or fright” Activated during exercise, excitement, andemergencies Parasympathetic – “rest and digest” Concerned with conserving energy
  8. 8. Anatomical Differences in Sympatheticand Parasympathetic Divisions Issue fromdifferent regionsof the CNS Sympathetic – alsocalled thethoracolumbardivision Parasympathetic –also called thecraniosacral division
  9. 9. Anatomical Differences in Sympatheticand Parasympathetic Divisions Length of postganglionic fibers Sympathetic – long postganglionic fibers Parasympathetic – short postganglionic fibers Branching of axons Sympathetic axons – highly branched Influences many organs Parasympathetic axons – few branches Localized effect
  10. 10. Sympathetic System Sympathetic preganglionic neurons areprimarly located in intermediolateral nucleusat the T1 to L2 levels of spinal cord Distribution of preganglionic fibers does notfollow dermatomal pattern of somatic nerves.
  11. 11. SPINAL SEGMENTS INNERVATIONT1 – T3 HEADT1 – T6 UPPER EXTREMITIESTHORACIC VISCERAT5 – T11 ABDOMINAL VISCERAT11 – L2 LOWER EXTREMITIESPELVIC & PERINEAL ORGANS
  12. 12. Typical Organisation Of A Spinal Nerve
  13. 13.  Preganglionic sympathetic axons exit throughventral roots and pass via white ramicommunicantes on corresponding spinal nerve toreach the paravertebral sympathetic chain Majority of them run rostrally or caudally alongthe sympathetic chain and synapse on largeparavertebral ganglia. Remaining fibers pass through paravertebralchain without synapsing and form splanchnicnerves that innervate prevertebral ganglia &adrenal glands
  14. 14. Sympathetic Pathways to PeripheryFigure 15.9
  15. 15. Sympathetic Trunk Ganglia Located on both sides of the vertebral column Linked by short nerves into sympathetictrunks They are the primary relay stations forpreganglionic inputs They innervate all tissues and organs exceptthose in abdomen, pelvis and perineum Fusion of ganglia  fewer ganglia than spinalnerves
  16. 16. Sympathetic Trunk Ganglia
  17. 17. Prevertebral Ganglia Unpaired, not segmentally arranged Occur only in abdomen and pelvis Lie anterior to the vertebral column Main ganglia Celiac, superior mesenteric, inferior mesenteric,inferior hypogastric ganglia
  18. 18. Sympathetic Outflow Sympathetic preganglionic neurons –organized into different functional units whichcontrol specific targets – Muscle vasomotor Splanchnic vasomotor Skin vasoconstrictor Skin vasodilator Cardiomotor Visceromotor preganglionic neurons
  19. 19.  Sympathetically induced vasoconstriction ofskeletal muscle and splanchnic vessels is criticalto avoid orthostatic hypotension ( alpha 1 ) Sympathetic outflow to skin blood vessels andsweat glands is critical for thermoregulation – exposure to cold – skin vasoconstrictionpiloerection ( alpha 1 ) exposure to heat – sweatingskin vasodilatation ( M3 )
  20. 20. Organ Parasympathetic Response"Rest and Digest" Sympathetic Response"Fight or Flight" Heart(baroreceptor reflex)Decreased heart rateCardiac output decreasesIncreased rate and strength ofcontractionCardiac output increases Lung Bronchioles Constriction Dilation Liver Glycogen No effectGlycogen breakdownBlood glucose increases Fat Tissue No effectBreakdown of fatBlood fatty acids increase Basal Metabolism No effect Increases ~ 2X StomachIncreased secretion of HCl & digestiveenzymes & Increased motilityDecreased secretionDecreased motility IntestineIncreased secretion of HCl & digestiveenzymes & Increased motilityDecreased secretionDecreased motility Urinary bladderRelaxes sphincterDetrusor muscle contractsUrination promotedConstricts sphincterRelaxes detrusorUrination inhibited RectumRelaxes sphincterContracts wall musclesDefecation promotedConstricts sphincterRelaxes wall musclesDefecation inhibited EyeIris constrictsAdjusts for near visionIris dilatesAdjusts for far vision Male Sex Organs Promotes erection Promotes ejaculation
  21. 21. The Role of the Adrenal Medulla inthe Sympathetic Division Major organ of the sympathetic nervoussystem Secretes great quantities epinephrine (a littlenorepinephrine) Stimulated to secrete by preganglionicsympathetic fibers
  22. 22. The Adrenal Medulla
  23. 23. Neurotransmitters of AutonomicNervous System Neurotransmitter released by preganglionicaxons Acetylcholine for both branches (cholinergic) Neurotransmitter released by postganglionicaxons Sympathetic – most release norepinephrine(adrenergic) Parasympathetic – release acetylcholine
  24. 24. How do we define neuron types in theANS?C OOCH2 CH2 NCH3CH3CH3CH3CH2 NCH3CH3CH3OHOH3CNCH3NHOHO CHOHCH2 NH2HOHO CHOHCH2 NHCH3ParasympatheticSympatheticAcetylcholineMuscarineNicotineNorepinephrine(Noradrenaline)Epinephrine(Adrenaline)
  25. 25. Anatomical Differences in Sympatheticand Parasympathetic Divisions
  26. 26. Anatomical Differences in Sympatheticand Parasympathetic Divisions
  27. 27. Summary of sympathetic neuronsand synapsesPreganglionic neurons Short Synapse with postganglionic neurons near spinal cord Release acetylcholine (ACH) to activate nicotinic receptors on postganglionic neuronsPostganglionic neurons Long Synapse on the target organ Release norepinephrine to activate adrenergic receptors on target organs
  28. 28.  Sweat glands:» Postganglionic neuronsinvolved with stress-relatedexcretion releasenorepinephrine (“sweatypalms”)» Postganglionic neuronsinvolved with thermoregulationrelease acetylcholineExceptions in the sympathetic nervous system:
  29. 29.  Kidneys:» Postganglionic neurons to thesmooth muscle of the renalvascular bed release dopamine Adrenal gland:» Preganglionic neurons do notsynapse in the paraverterbralsympathetic ganglion» Preganglionic neurons synapsedirectly on the adrenal gland,release acetylcholine, and activatenicotinic receptors on the adrenalgland» Adrenal glands release epinephrineinto systemic circulationExceptions in the sympathetic nervous system:
  30. 30. Stellate ganglion blockindications, procedure andcomplications
  31. 31.  The stellateganglion (or cervicothoracicganglion or inferior cervical ganglion) isa sympathetic ganglion formed by thefusion of the inferior cervicalganglion and the firstthoracic ganglion. It is located at the level of C7 (7thcervical vertebrae), anterior tothe transverse process of C7, anterior tothe neck of the first rib, and just below thesubclavian artery.Stellate ganglion
  32. 32. AnatomyAnteriorThe structures anterior to theganglion include the skin andsubcutaneous tissue, thesternocleidomastoid and thecarotid sheath. The dome of thelung lies anterior and inferior tothe ganglion
  33. 33.  MedialThe prevertebral fascia, vertebral body ofC7, oesophagus and thoracic duct liemedially PosteriorStructures posterior to the ganglion includethe longus colli muscle, anterior scalenemuscle, vertebral artery, brachial plexussheath and neck of the first rib.CONTINUED……
  34. 34. Chassaignac’s tubercleThis is the anterior tubercleof the transverse processof the sixth cervicalvertebra, which lies lateralto and at a slightly higherlevel than the posteriortubercle, and against whichthe carotid artery may becompressed by the finger.
  35. 35.  Stellate Ganglion block is an injection oflocal anaesthetic in the "sympatheticnerve tissue" - the nerves which are a partof Sympathetic Nervous System The injection consists of a local anaesthetic(like lidocaine or bupivacaine). Epinephrine(adrenaline) may be added to prolong theeffects of the injectionStellate ganglion block
  36. 36.  A stellate ganglion block blocks the sympatheticnerves that go to the arms, and, to somedegree, the sympathetic nerves that go to theface. This may in turn reduce pain, swelling, colourand sweating changes in the upper extremityand may improve mobility. It is done as a part of the treatment of ReflexSympathetic Dystrophy (RSD), SympatheticMaintained Pain, Complex Regional PainSyndrome and Herpes Zoster (shingles)involving an arm or the head and face.Purpose of block
  37. 37.  Pain syndromes Complex regional pain syndrome type I and II Refractory angina Phantom limb pain Herpes zoster Shoulder/hand syndrome AnginaIndications
  38. 38.  Vascular insufficiency Raynauds syndrome Scleroderma Frostbite Obliterative vascular disease Vasospasm Trauma EmboliCONTINUED…
  39. 39.  Coagulopathy Recent myocardial infarction Pathological bradycardia Glaucoma Allergy to medicationsCONTRAINDICATIONS
  40. 40. The patient is placed in the supine positionwith the neck slightly extended, the headrotated slightly to the side opposite the block,and the jaw open.The point of needle puncture is locatedbetween the trachea and the carotid sheathat the level of the cricoid cartilage andChassaignacs tubercleProcedure
  41. 41. Technique
  42. 42.  Cutaneous anaesthesia is obtained with askin wheal of local anaesthetic. The sternocleidomastoid and carotid arteryare retracted laterally as the index and middlefingers palpate Chassaignacs tubercle The needle is directed onto the tubercle, andthen redirected medially and inferiorly towardthe body of C6.Technique
  43. 43.  After the body is contacted, the needle iswithdrawn 1-2 mm This brings the needle out of the belly of thelongus colli muscle, which sits posterior to theganglion and runs along the anterolateralsurface of the cervical vertebral bodies . The needle is then held immobile.Technique
  44. 44. Technique 10 ml control syringe charged with localanaesthetic is attached to the needle and aspirationis performed to rule out intravascular placement. A 0.5 ml test dose is performed to rule outintravascular injection into the vertebral artery,sinceseizures can occur immediately, even with verysmall volumes of local anaesthetic. This test dose is followed by a 3 ml epinephrine-containing test dose to rule out intravenousplacement.Now the remaining drug is also injected.
  45. 45.  Horner’s syndrome The onset of Horners syndrome indicates asuccessful block.Horners syndrome is characterised by aninterruption of the oculosympathetic nervepathway somewhere between its origin in thehypothalamus and the eyeSuccessful block
  46. 46. SignsThe classic clinicalfindings associated withHorners syndrome are• ptosis• pupillary miosis• facial anhidrosis
  47. 47. Other findings may include apparent enophthalmos increased amplitude of accommodation heterochromia of the irides (if it occursbefore the age of 2 years) paradoxical contralateral eyelid retraction transient decrease in intraocular pressureand changes in tear viscosityHorner ‘s syndrome
  48. 48.  Misplaced needleHaematoma from vascular traumaCarotid traumaInternal jugular vein traumaNeural injuryVagus injuryBrachial plexus roots injuryPulmonary injuryPneumothoraxHaemothoraxChylothorax (thoracic duct injury)Oesophageal perforationComplications
  49. 49. Spread of local anaesthetic Intravascular injection:Carotid arteryVertebral arteryInternal jugular vein Neuraxial/brachial plexus spread:Epidural blockIntrathecalBrachial plexus anaesthesia or injury (intraneural injection) Local spread:Horseness (recurrent laryngeal nerve)Elevated hemidiaphragm (phrenic nerve)Compliccations
  50. 50.  InfectionSoft tissue (abscess)Neuraxial (meningitis)OsteitisComplications
  51. 51.  Stellate ganglion block is done to: Diagnose the cause of pain in the face andhead, arms and chest Manage pain in the head, neck, chest or armcaused by nerve injuries, the effects of an attackof shingles (herpes zoster) or angina thatdoesnt go away Reduce sweating in the face, head, arms andhands Treat reflex sympathetic dystrophy, sympatheticmaintained pain or complex regional painsyndromeSummary
  52. 52. Textbook Of Human PhysiologyGuyton And HallClinical anesthesiology4theditionG. Edward MorganReferencesClinical anesthesia6theditionpaul G. BraschNet references from wikipedia.com and frca.co.uk

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