this is dr greg hickman from the andrews institute today we're going to do some brachial plexus blocks and we're going to start with a supraclavicular block this young lady is having some elbow surgery and ulnar nerve release and a carpal tunnel release and so we're going to superclavicular block mainly we're going to want to get the uh corner pocket the lower part of the brachial plexus the lower cord which will have the ulnar nerve and the lower trunk i mean and uh we'll start there and then work our way up uh the we're gonna use the uh clarius ultrasound probe which is wireless and we'll use my ipad here as as our uh what we'll be seeing the nerves on the ultrasound image with and we'll get started here all right we're going to start with the probe just above the clavicle kind of parallel to the clavicle and aiming straight down towards the toes i've got her in a little bit of a head up position here so you can see the the subclavian artery beating and right below it you see a nice first rib and below the first ribs the white line and then below its dark cause bone and impedes ultrasound penetration so it's going to be dark under bone now what we're going to do is take the probe and just rotate it a little bit posterior so you can see the nerves there now you can see the nerve sitting right on the on the first rib and you see the lower trunk where we're going to get right under and i'm going to increase the gain it's really easy just slide a little bit to the right on the on the screen of the uh of the ipad so we're going to put a little number shot in here one two three there we go and we're going to use a uh stimulating needle so if we get too close to theirs we'll get a twitch come in posteriorly here getting a little twitch there so we'll back up okay here we come so you can see the needle you can see the rib we know it's safe here we can advance hitting the rib actually there so i'm going to come back and try to get a little further over close to the artery i want to get as close to the artery as i can and lift up this plexus all right rocky give us five cc's right there and see if that lift up our nerves beautiful just like that okay so that looks really good now i want to come up a little higher try to separate the other trunks coming in more up here we've got our corn pocket good okay we're getting a twitch there kind of hard here sometimes you can peel off the upper trunk really easy this one's not going to be so easy getting some twitches there give us a slip five right there rocky and let's see what we can open up here one two there you go three okay all right so we open up a little bit we're going to come back and come in up here see if we can get in a little further closer to the artery nope well actually i might do this try to peel off the upper trunk a little bit all right i could give us five right here trying to peel off the upper trunk two three thanks there we go actually keep going right there there we go actually i think we got between the middle and the lower trunks there now we'll try to get up here and get this upper trunk a little bit sometimes if the over trunk is open you can get right under it pretty easily if it's really packed in tight like this sometimes i'll just scan up the neck and i can see it a little better here and we'll come in and approach like this and try to get the upper trunk here really need the middle and lower trunk so it's not that big a deal on this case but actually i'll just come over the top here give me five here and we'll get the upper trunk real easy here two three there we go all right now we got five left so i'm gonna go back down and finish off down in the uh in the corner pocket get my needle here where i can see it there's our needle we're going to go right down underneath the nerves between the nerves and the rib you know we're close to the artery and pulling in there so i'm going to go a little bit lower there we go now okay let's give our last five right here rocky this will be a total of 30 cc's a quarter percent boop cane yep right there beautiful we'll pull back pull back looking good beautiful and that concludes our supraclavicular block again a great case for a regional aesthetic great case for a wireless ultrasound probe the clarius really nice images that we can use so that'll finish up this supraclavicular block thank you you
