hi this is dr greg hickman uh from the andrews institute we're gonna we got a young man having some thumb surgery and we're gonna do a brachial plexus block on him and get him nice and numb we got him a little comfortable here for this block we've got a little verse set on board and we do an infraclavicular block on him with brachial plexus or with hand surgery you can do a brachial plexus block at three different positions you can do a supraclavicular you can do an infraclavicular or an axillary block they all work basically similarly and you get the same results so for hand elbow surgery we can use any any one of those three blocks let's put the probe basically the same place and come in behind the clavicle retro to the clavicle you can see the artery there you can see on the right side of the screen the uh the clavicle and you're going to come underneath that so it's it's you're not going to see the needle till it gets past the clavicle and gets over towards the cords and there you go you can see the cords pretty well right there so that's where we're going to go i'm going to turn this around so that we're coming in from the left side like we are on the on the on the probe you get the same same view right there nice view right there you see the pec major the pec minor the subclavian artery with it with the lateral cord on the left of the artery the posterior cord down about seven o'clock don't really see it well and the medial cord over about three o'clock those are the cords we're going to just make a little u around the artery and get our local uh dispersed in that fashion okay all right gonna wash off here it's a little chlorhexidine prep prep things up all right i gotta go left-handed that's not my strong suit but i can get it done and big beasting right here at the skin wheel all right i'll bring our stimulating needle in people do call this the raptor because we're going retrograde to the clavicle here really nice view there the subclavian artery pec major pec minor and i'm going to come in under the clavicle see where we are it's kind of hard because the clavicle you have to sort of ride up on the clavicle sometimes when you're coming in you see the needle there and i want to add a little twitch with the lateral cord i want to come back with a needle i want to go a little deeper come in here now i'm coming up close to the artery and i'm just going to lift up i'll probably get a twitch right here that's the lateral cord get the muscular cutaneous twitch so just give me five right there rocky five cc's on the lateral cord there and then sometimes you can go over the top of the lateral cord sometimes i'll come right in here between that lateral cord and the artery i might be getting posterior twitch there huh okay actually i'm just going to go back and go deeper and go underneath the artery here pick that up actually just give me five right there rocky pick that up a little bit more much more of the lateral core okay now i'm going to come on under the artery here actually the posterior cord should be down here well anyway a lot of times you don't get the posterior cord twitch so we're just going to slide under the artery now and if you really can't see the cords well i'm not sure exactly where to go and you don't get twitches so there's our medial cord twitch you can see the hand uh giving us a little twitch there so let's do five right there there you go might be just pushing that nerve down that cord down right but what i was what i was about to say was if you don't see it well if you just go right here under the artery you can put all 30 cc's just about six o'clock or from four to six o'clock and and that'll make a nice u around the artery so where's our needle right here now watch this i'm underneath the artery but i can pull the needle up it looks like the needle's going right through the middle of the artery it's not we're still deep to it as i come down here so give me uh let's give five more right here since we got a twitch there we go try to advance a little bit there we go now i'm over on the medial side of the artery and let's do five more right there there we go you can see the vein on the medial side there and i'm filling up local right between the vein and the artery and now i'm gonna we got five left so i'm just gonna pull back and put this last five kind of right under the artery and find the needle again there it was okay okay looks like my tip's about seven o'clock that's where the lateral and posterior cords should be right above and below it so we get the last five right there at seven o'clock to the artery uh-huh yeah get right there nice spread there beautiful okay so that's 30 cc's of half percent bupivacaine for the single shot brachial plexus block for his thumb surgery and that will complete our infraclavicular block for this thumb surgery thank you you
