Use of Stellate Ganglion Block to Treat Post-Traumatic Stress Disorder (PTSD) - Jennifer Hodge, BSN, RN, CCRN, SRNA Duke Nurse Anesthesia Program ...

Use of Stellate Ganglion Block
to Treat Post-Traumatic Stress
Disorder (PTSD)

   Jennifer Hodge, BSN, RN, CCRN, SRNA
       Duke Nurse Anesthesia Program
                Class of 2014

About Me…

About Me…

Dominican Republic

Objectives:
• Define Post-Traumatic Stress Disorder (PTSD) and
  understand diagnostic criteria of this disorder.
• Understand the prevalence of PTSD in the current
  population.
• Discuss current pharmacological treatments for PTSD
  and their downfalls.
• Correctly identify the anatomy of Stellate Ganglion.
• Understand the theory and mechanism of action
  explaining how the stellate ganglion block can treat
  PTSD.

What is PTSD?
PTSD is a debilitating psychological
condition triggered by a major traumatic
event.
  • Military Combat/War
  • Violent personal assault
    • Physical attack, mugging, rape, robbery, kidnapping
  • Terrorist attacks
    • 9/11, Oklahoma bombing, World Trade Center Bombing,
      random public shootings
  • Severe accidents
  • Natural disasters
    • Tsunami, earthquake, hurricane

• “Soldier’s Heart”-
  1876
• DSM III- 1980
• Currently
  diagnosed with
  DSM-V
  (May 2013)

Some History…

PTSD Diagnosis
• Adults, adolescents, and children older than six
  years.
• Multiple criteria must be met to receive diagnosis
• Symptoms grouped into four different categories
• Time frame and exclusion criteria also present

Criterion A:
                     Stressor
The person was exposed to: death, threatened death,
actual or threatened serious injury, or actual or
threatened sexual violence, as follows: (one required)
• Direct exposure
• Witnessing (in person)
• Indirectly, by learning that a close relative or friend
  was exposed to trauma or death
• Repeated or extreme indirect exposure to aversive
  details of the event(s), usually in the course of
  professional duties.

Criterion B:
             Intrusion Symptoms
 The traumatic event is persistently re-experienced in
         the following way(s): (one required)
• Recurrent, involuntary, and intrusive memories.
• Traumatic nightmares.
• Dissociative reactions (e.g., flashbacks) which may
  occur on a continuum from brief episodes to
  complete loss of consciousness.
• Intense or prolonged distress after exposure to
  traumatic reminders.
• Marked physiologic reactivity after exposure to
  trauma-related stimuli.

Criterion C:
                    Avoidance
Persistent effortful avoidance of distressing
trauma-related stimuli after the event: (one
required)
• Trauma-related thoughts or feelings.
• Trauma-related external reminders (e.g.,
  people, places, conversations, activities,
  objects, or situations).

Criterion D:
 Negative Alterations in Cognition and Mood
Negative alterations in cognition and mood that
began or worsened after the traumatic event: (two
required)
• Inability to recall key features of the traumatic event
• Persistent (and often distorted) negative beliefs and
  expectations about oneself or the world
• Persistent distorted blame of self or others for causing
  the traumatic event or for resulting consequences
• Persistent negative trauma-related emotions
• Markedly diminished interest in (pre-traumatic)
  significant activities.
• Feeling alienated from others
• Constricted affect: persistent inability to experience
  positive emotions.

Criterion E:
      Alterations in Arousal and Reactivity
Trauma-related alterations in arousal and reactivity
that began or worsened after the traumatic event:
(two required)
• Irritable or aggressive behavior
• Self-destructive or reckless behavior
• Hypervigilance
• Exaggerated startle response
• Problems in concentration
• Sleep disturbance

Criterion F:
                     Duration
Persistence of symptoms (in Criteria B, C, D, and E)
for more than one month.

                   Criterion G:
              Functional Significance
Significant symptom-related distress or functional
impairment (e.g., social, occupational).

              Criterion H: Exclusion
Disturbance is not due to medication, substance use, or
other illness.

•   Hypervigilance
•   Exaggerated startle response
•   Fear and anxiety
•   Nightmares and flashbacks, including
    sight, sound, and smell recollection
•   Avoidance of recall situations
•   Anger and irritability
•   Guilt
•   Depression
•   Increased substance abuse
•   Negative world view

Treatments                           Downfalls

 • SSRIs- 1st line treatment         • Duration of medication
   • Zoloft, Paxil, Prozac, Celexa     onset and “drop out”
 • Seroquel- off label use           • Somnolence & Fatigue
 • Alpha1 antagonist                 • Sexual Dysfunction
   • Prazosin
                                     • Increased risk of suicide
 • Alpha2 agonist
                                     • Polypharmacy
   • Clonidine

Methylenedioxymethamphetamine
           (MDMA)

Stellate Ganglion Anatomy

Stellate Ganglion Block

•   Infection
•   Bleeding
•   Intravascular injection
•   Subarachnoid injection
•   Local anesthetic toxicity
•   Pneumothorax
•   Allergic reaction

Potential Complications

•   Migraines
•   Complex Regional Pain Syndrome (CRPS)
•   Atypical face pain- Herpes Zoster
•   Hot flashes
•   Raynaud’s phenomenon
•   Craniofacial Hyperhidrosis
•   PTSD?????

Current Uses for SGB

• Pseudorabies virus
  mapping in rats
  (Westerhaus &
  Loewy, 2001)
• Connections
  established between
  Stellate Ganglion and
  insular and
  infralimbic cortical
  regions, hypothalmus
  and amygdala.

•   48 year old male
•   Victim of physical assault
•   One week post event- prescribed three medications
•   New symptoms at 23 days post event.
•   Relaxation therapy started but unsuccessful.
•   SGB done at day 55 post trauma

Case Study 1

• Pt reported immediate decrease in anxiety
• Change in symptoms and medication usage
  one week post SGB
• Repeat of SGB with pulsed radiofrequency
  done at day 32 d/t return of symptoms
• Follow up three months later, pt reported
  90% improved

Results

• Right sided SGB
• Radiographic confirmation of right C6 transverse process
• Skin localized and 25 ga. Quincke needle placed via anterior
  paratracheal approach under fluoroscopic guidance
• 2 cc radio-opaque dye injected to visualize spread.
• 7 cc of 0.5% Ropivicaine injected slowly after neg. aspirate
• Pt monitored for horner’s syndrome, facial anhidrosis and
  temperature change in right hand x 15 mins.

Procedure for Case Studies 2 & 3

46 yr male retired military involved in close range
combat event, where he was rendered unconscious from
an explosion.
• PCL score 76 out of 85
• 1 year psychiatric treatment prior to SGB
• On multiple medications:
  • Zoloft, Seroquel, Trazadone, Effexor, and Ambien
• Experiencing multiple side effects from current medication
  • somnolence, sexual dysfunction and auto accident
    d/t falling asleep at wheel.

Case Study 2

• Improvement 5 minutes after block placement
• Anxiety score decreased from 8 to 2
• Tapered off all medications except Ambien
• Able to sleep for 6-7 hrs per night
• Nightmares diminished in both intensity &
  frequency
• Remission for 3 mths, procedure repeated at 7
  mths d/t return of symptoms and PCL of 67.
• 4 months after 2nd procedure- off all psychotropic
  meds and PCL score of 34

Results

36 yr. old active duty male involved in Battle of
Fallujah during Operation Iraqi Freedom.

• PCL score of 54
• 1 year psychiatric care prior to SGB
• Medications
  • Mirtazapine, Ambien and Zoloft

Case Study 3

• Immediate improvement in anxiety levels post
  SGB
• PCL score of 24 which remained consistent at 7
  month follow up
• Discontinued all medications with resolution of
  adverse side effects

Results

The Future??

References
•   (2010). In search of an effective treatment for combat-related post-traumatic stress disorder (ptsd): Can
    stellate ganglion block be the answer?. World Institute of Pain, 10(4), 265-266.
•   Alleva, E., Petruzzi, S., Cirulli, F., & Aloe, L. (1996). NGF regulatory role in stress and coping of rodents and
    humans. Pharmacology Biochemistry and Behavior, 1(54), 65-72
•   Freidman, M.J., Resick, P.A., Bryant, R.A., Brewin, C.R. (2010). Considering PTSD for DSM-5. Depression
    and Anxiety, 1-20. DOI 10.1002/da.20767
•   Lipov, E. G., Joshi, J. R., Sanders, S., & Slavin, K. V. (2009). A unifying theory linking the prolonged
    efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes
    and posttraumatic stress disorder (PTSD), Medical Hypotheses, 72, 657-661.
•   Lipov, E., Kelzenberg, B., Rothfeld, C., & Abdi, S. (2012). Modulation of NGF by cortisol and the stellate
    ganglion block-is this the missing link between memory consolidation and PTSD?. Medical Hypotheses, 79,
    750-753.
•   Lipov, E., Kelzenberg, B., (2012). Sympathetic system modulation to treat post-traumatic stress disorder
    (PTSD): A review of clinical evidence and neurobiology. Journal of Affective Disorders, 1-3(142), 1-5.
•   Lipov, E.G., Lipov, S., Sanders, S.E., Siroko, M.K. (2008). Letter to the Editor: Cervical Symptathetic
    Blockade in a Patient with Post-Traumatic Stress Disorder: A Case Report. Annals of Clinical Psychiatry,
    20(4), 227-228.
•   Mulvaney, S.W., McLean, B., Leeuw, J.D. (2010). The Use of Stellate Ganglion Block in the Treatment of
    Panic/Anxiety Symptoms with Combat-Related Post-Traumatic Stress Disorder; Preliminary Results of Long-
    Term Follow up: A Case Study. World Institute of Pain, 4(10), 359-365.
•   Westerhaus, M.J., Loewry, A.D., (2001). Central Representation of the sympathetic nervous system in the
    cerebral cortex. Brain Research. 903, 117-127.