Corner pocket supraclavicular block (Reg Anes and Pain Med 2007;32(1):94)
ultrasound guide supraclavicular block (Am J Emerg Med 2007;25;472) 1. Introduction Emergency physicians often encounter patients who require anesthesia for the treatment of acute traumatic or infectious processes. Direct infiltration of a local anesthetic agent may be insufficient to obtain adequate anesthesia for upper extremity fractures, dislocations, and abscesses. Although procedural sedation can facilitate the treatment of these patients, it requires patients to have fasted for 6 or more hours and still involves the risk of apnea, hypotension, and other adverse effects. Peripheral nerve blocks (of the median, ulnar, and radial nerves) in the upper extremity are effective but require multiple injections and are unable to provide effective anesthesia proximal to the forearm . The success of real-time ultrasound-guided supraclavicular brachial plexus nerve blocks has been reported extensively in the anesthesiology literature , , ,  and . These studies used both real-time ultrasound guidance and nerve stimulation to confirm needle position. We hypothesize that real-time ultrasound-guided brachial plexus nerve blocks can be performed without nerve stimulation and can provide an excellent alternative to procedural sedation for the management of upper extremity fractures, dislocations, or abscesses in the emergency department (ED). We report a series of 5 ED patients in whom supraclavicular brachial plexus nerve blocks were performed using ultrasound guidance. 2. Methods The procedure for ultrasound-guided supraclavicular brachial plexus nerve block was modified from the technique originally described by Chan . After written informed consent was obtained, the supraclavicular fossa was prepared and draped in sterile fashion. A sonographic view of the brachial plexus was obtained with a 10 to 5.0 MHz linear transducer oriented transversely in the supraclavicular fossa, just above the clavicle. In this view, the brachial plexus is superficial and lateral to the subclavian artery and is visualized as a group of hypoechoic nodules ( Fig. 1). Arterial flow was confirmed by pulsed wave Doppler flow to ensure the correct identification of the subclavian artery. A 27-gauge or a 22-gauge noncutting spinal needle was inserted from the lateral aspect of the linear transducer and directed in parallel with the transducer to allow visualization of the full length of the needle throughout the procedure ( Fig. 2). When the needle tip was visualized adjacent to the hypoechoic nodules representing the brachial plexus, 30 mL of lidocaine 1% with epinephrine was instilled with frequent aspiration to avoid intravascular injection. The spread of local anesthetic within the brachial plexus was visualized as an expanding hypoechoic collection within the brachial plexus. This technique is similar to the one described by Chan et al , yet does not involve the use of a nerve stimulator needle given the lack of availability and familiarity with this device in the ED.
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