<p begin="00:00:07.354" end="00:00:09.128" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.128" end="00:00:11.643" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.643" end="00:00:15.694" style="s2">an ultrasound-guided,<br />infraclavicular regional nerve block.</p>
<p begin="00:00:15.694" end="00:00:19.134" style="s2">The target depth is approximately<br />three to four centmeters</p>
<p begin="00:00:19.134" end="00:00:21.341" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:21.341" end="00:00:23.542" style="s2">The patient is positioned supine</p>
<p begin="00:00:23.542" end="00:00:25.523" style="s2">with the arm abducted 90 degrees</p>
<p begin="00:00:25.523" end="00:00:27.616" style="s2">and the elbow bent 90 degrees</p>
<p begin="00:00:27.616" end="00:00:29.525" style="s2">to move the clavicle posterior,</p>
<p begin="00:00:29.525" end="00:00:32.434" style="s2">and permit a shallow<br />angle of needle insertion.</p>
<p begin="00:00:32.434" end="00:00:34.126" style="s2">The patient's head should be rotated</p>
<p begin="00:00:34.126" end="00:00:36.427" style="s2">toward the contralateral side.</p>
<p begin="00:00:36.427" end="00:00:40.380" style="s2">The transducer is placed on the<br />chest in a paramedian plane,</p>
<p begin="00:00:40.380" end="00:00:42.936" style="s2">inferior to the midpoint of the clavicle</p>
<p begin="00:00:42.936" end="00:00:46.372" style="s2">with the orientation marker<br />directed to the patient's head.</p>
<p begin="00:00:46.372" end="00:00:48.368" style="s2">The axillary artery is seen as</p>
<p begin="00:00:48.368" end="00:00:52.247" style="s2">a dark, round pulsatile<br />structure with a hyperechoic wall</p>
<p begin="00:00:52.247" end="00:00:56.144" style="s2">inferior to the pectoralis<br />major and minor muscles.</p>
<p begin="00:00:56.144" end="00:00:59.668" style="s2">The axillary vein lies<br />beside the axillary artery</p>
<p begin="00:00:59.668" end="00:01:01.751" style="s2">and collapses with compression.</p>
<p begin="00:01:01.751" end="00:01:04.801" style="s2">The nerve cords appear<br />as hyperechoic circles</p>
<p begin="00:01:04.801" end="00:01:06.193" style="s2">with a honeycomb appearance</p>
<p begin="00:01:06.193" end="00:01:10.370" style="s2">within the bright hyperechoic<br />fascia of the brachial plexus.</p>
<p begin="00:01:10.370" end="00:01:13.618" style="s2">The transducer is slowly<br />moved in a lateral direction,</p>
<p begin="00:01:13.618" end="00:01:16.454" style="s2">following the course<br />of the axillary artery.</p>
<p begin="00:01:16.454" end="00:01:18.722" style="s2">The nerves will split into a lateral,</p>
<p begin="00:01:18.722" end="00:01:21.793" style="s2">medial, and posterior cord.</p>
<p begin="00:01:21.793" end="00:01:24.069" style="s2">The optimum position of the transducer</p>
<p begin="00:01:24.069" end="00:01:26.136" style="s2">for the infraclavicular nerve block</p>
<p begin="00:01:26.136" end="00:01:28.306" style="s2">is as lateral as possible.</p>
<p begin="00:01:28.306" end="00:01:31.280" style="s2">The needle is positioned<br />two centimeters cephalad</p>
<p begin="00:01:31.280" end="00:01:35.432" style="s2">to the transducer and advanced<br />using an in-plane technique.</p>
<p begin="00:01:35.432" end="00:01:37.913" style="s2">The needle path is<br />directed over the clavicle</p>
<p begin="00:01:37.913" end="00:01:40.181" style="s2">and through the pectoral muscles.</p>
<p begin="00:01:40.181" end="00:01:42.143" style="s2">The initial endpoint for the needle is</p>
<p begin="00:01:42.143" end="00:01:45.627" style="s2">immediately posterior to<br />the midpoint of the artery.</p>
<p begin="00:01:45.627" end="00:01:48.770" style="s2">The spread of local<br />anesthetic should be observed.</p>
<p begin="00:01:48.770" end="00:01:52.364" style="s2">Supplemental injections can<br />be made anterior to the artery</p>
<p begin="00:01:52.364" end="00:01:53.954" style="s2">to deposit local anesthetic</p>
<p begin="00:01:53.954" end="00:01:57.954" style="s2">around the lateral and<br />medial cords if required.</p>

<p begin="00:00:13.602" end="00:00:16.030" style="s2">- The infraclavicular<br />block is used for surgery</p>
<p begin="00:00:16.030" end="00:00:17.898" style="s2">below the mid-humerus.</p>
<p begin="00:00:17.898" end="00:00:21.592" style="s2">Any surgery of the elbow,<br />forearm, wrist or hand</p>
<p begin="00:00:21.592" end="00:00:24.759" style="s2">can be performed under a properly executed</p>
<p begin="00:00:24.759" end="00:00:27.369" style="s2">infraclavicular block.</p>
<p begin="00:00:27.369" end="00:00:30.945" style="s2">Many people use curvilinear, low-frequency</p>
<p begin="00:00:30.945" end="00:00:35.112" style="s2">or mid-frequency probe to do<br />the infraclavicular block.</p>
<p begin="00:00:36.067" end="00:00:38.153" style="s2">With proper positioning</p>
<p begin="00:00:38.153" end="00:00:40.450" style="s2">you can do a infraclavicular block</p>
<p begin="00:00:40.450" end="00:00:42.617" style="s2">with a basic linear probe.</p>
<p begin="00:00:43.712" end="00:00:46.126" style="s2">I'm gonna demonstrate<br />the infraclavicular block</p>
<p begin="00:00:46.126" end="00:00:47.742" style="s2">with a basic linear probe</p>
<p begin="00:00:47.742" end="00:00:49.990" style="s2">because most people have a linear probe</p>
<p begin="00:00:49.990" end="00:00:52.573" style="s2">in their ultrasound repertoire.</p>
<p begin="00:00:53.558" end="00:00:54.622" style="s2">Proper positioning for</p>
<p begin="00:00:54.622" end="00:00:58.278" style="s2">the infraclavicular block is important.</p>
<p begin="00:00:58.278" end="00:01:00.373" style="s2">We usually keep the patient supine</p>
<p begin="00:01:00.373" end="00:01:02.502" style="s2">for infraclavicular block.</p>
<p begin="00:01:02.502" end="00:01:05.405" style="s2">We also move the patient<br />completely to the other side</p>
<p begin="00:01:05.405" end="00:01:08.680" style="s2">of the bed of the site to be blocked.</p>
<p begin="00:01:08.680" end="00:01:12.118" style="s2">Abduction of the arm<br />moves the clavicle down</p>
<p begin="00:01:12.118" end="00:01:14.694" style="s2">and out of the way of your needle.</p>
<p begin="00:01:14.694" end="00:01:16.806" style="s2">If the arm is down by the side</p>
<p begin="00:01:16.806" end="00:01:19.862" style="s2">our needle approach is gonna<br />bump into the clavicle.</p>
<p begin="00:01:19.862" end="00:01:21.485" style="s2">Usual depth settings</p>
<p begin="00:01:21.485" end="00:01:24.503" style="s2">for infraclavicular<br />block in a normal patient</p>
<p begin="00:01:24.503" end="00:01:28.799" style="s2">usually range between four to<br />six centimeters total depth.</p>
<p begin="00:01:28.799" end="00:01:32.639" style="s2">Ultrasound probe positioning<br />in the infraclavicular region</p>
<p begin="00:01:32.639" end="00:01:37.598" style="s2">is done in the parasagittal<br />plane below the clavicle.</p>
<p begin="00:01:37.598" end="00:01:38.918" style="s2">I will orient the probe</p>
<p begin="00:01:38.918" end="00:01:42.005" style="s2">so the left side of the screen is caudal</p>
<p begin="00:01:42.005" end="00:01:45.470" style="s2">and the right side of<br />the screen is cranial.</p>
<p begin="00:01:45.470" end="00:01:47.510" style="s2">This makes sense because if I bring</p>
<p begin="00:01:47.510" end="00:01:50.334" style="s2">the needle from the<br />cranial side on the screen</p>
<p begin="00:01:50.334" end="00:01:52.110" style="s2">it will also come from the right side.</p>
<p begin="00:01:52.110" end="00:01:54.055" style="s2">The first thing we see here</p>
<p begin="00:01:54.055" end="00:01:55.972" style="s2">is the pectoralis major</p>
<p begin="00:01:57.447" end="00:02:00.143" style="s2">and we also will see a pectoralis minor</p>
<p begin="00:02:00.143" end="00:02:02.718" style="s2">if I move slightly lateral.</p>
<p begin="00:02:02.718" end="00:02:06.965" style="s2">Here we now have identified<br />both the axillary vein</p>
<p begin="00:02:06.965" end="00:02:09.118" style="s2">and the axillary artery.</p>
<p begin="00:02:09.118" end="00:02:13.336" style="s2">The vein is found more<br />caudal than the artery.</p>
<p begin="00:02:13.336" end="00:02:16.076" style="s2">The artery is found cranial.</p>
<p begin="00:02:16.076" end="00:02:20.280" style="s2">Around the artery we<br />now identify our nerves.</p>
<p begin="00:02:20.280" end="00:02:21.905" style="s2">The nerves at this level</p>
<p begin="00:02:21.905" end="00:02:24.049" style="s2">are the cords of the brachial plexus.</p>
<p begin="00:02:24.049" end="00:02:26.881" style="s2">Traditionally the medial<br />cord is described as being</p>
<p begin="00:02:26.881" end="00:02:29.697" style="s2">approximately seven to ten o'clock</p>
<p begin="00:02:29.697" end="00:02:32.114" style="s2">on the artery in this picture.</p>
<p begin="00:02:32.114" end="00:02:34.537" style="s2">The posterior cord is described around</p>
<p begin="00:02:34.537" end="00:02:36.608" style="s2">six o'clock on the artery</p>
<p begin="00:02:36.608" end="00:02:38.945" style="s2">and the lateral cord is<br />described between three</p>
<p begin="00:02:38.945" end="00:02:41.945" style="s2">and six o'clock on this picture.</p>
<p begin="00:02:41.945" end="00:02:45.126" style="s2">It's difficult to see individual nerves</p>
<p begin="00:02:45.126" end="00:02:47.679" style="s2">because this is a deep block.</p>
<p begin="00:02:47.679" end="00:02:50.358" style="s2">So the important thing<br />is to surround the artery</p>
<p begin="00:02:50.358" end="00:02:52.518" style="s2">with local anesthetic.</p>
<p begin="00:02:52.518" end="00:02:54.758" style="s2">Now if we move more medially</p>
<p begin="00:02:54.758" end="00:02:58.751" style="s2">we see some lung on the bottom<br />left side of the screen here.</p>
<p begin="00:02:58.751" end="00:03:02.545" style="s2">Lateral approaches to the<br />infraclavicular block are safer</p>
<p begin="00:03:02.545" end="00:03:04.830" style="s2">because the more lateral you are</p>
<p begin="00:03:04.830" end="00:03:08.997" style="s2">the less likely you are to<br />enter the lung with your needle.</p>
<p begin="00:03:09.962" end="00:03:13.095" style="s2">Typically we use about<br />20 to 30 milliliters</p>
<p begin="00:03:13.095" end="00:03:16.582" style="s2">of local anesthetic for<br />infraclavicular block.</p>
<p begin="00:03:16.582" end="00:03:18.985" style="s2">Our first injection of the artery</p>
<p begin="00:03:18.985" end="00:03:20.905" style="s2">will be below the artery.</p>
<p begin="00:03:20.905" end="00:03:23.492" style="s2">Some studies have described<br />a single injection</p>
<p begin="00:03:23.492" end="00:03:26.586" style="s2">resulting in a complete<br />brachial plexus block</p>
<p begin="00:03:26.586" end="00:03:31.260" style="s2">by depositing our entire local<br />anesthetic below the artery.</p>
<p begin="00:03:31.260" end="00:03:34.721" style="s2">Usually I do my first<br />injection below the artery</p>
<p begin="00:03:34.721" end="00:03:36.253" style="s2">and look at the spread.</p>
<p begin="00:03:36.253" end="00:03:38.906" style="s2">If the spread is adequate I'll stop there.</p>
<p begin="00:03:38.906" end="00:03:42.010" style="s2">If I need to position the<br />needle in other places</p>
<p begin="00:03:42.010" end="00:03:44.017" style="s2">I'll go either to the lateral cord</p>
<p begin="00:03:44.017" end="00:03:45.937" style="s2">or approximately three o'clock</p>
<p begin="00:03:45.937" end="00:03:48.242" style="s2">and then lastly at the medial cord</p>
<p begin="00:03:48.242" end="00:03:51.882" style="s2">which would be about ten<br />o'clock on the artery.</p>
<p begin="00:03:51.882" end="00:03:54.481" style="s2">Complete spread of local<br />anesthetic around the artery</p>
<p begin="00:03:54.481" end="00:03:58.385" style="s2">will result in a good<br />brachial plexus block.</p>
<p begin="00:03:58.385" end="00:04:01.497" style="s2">In this image of the infraclavicular block</p>
<p begin="00:04:01.497" end="00:04:04.474" style="s2">we see the local anesthetic being injected</p>
<p begin="00:04:04.474" end="00:04:07.433" style="s2">cranial to the axillary artery.</p>
<p begin="00:04:07.433" end="00:04:10.766" style="s2">Superficial we see the pectoralis major.</p>
<p begin="00:04:12.256" end="00:04:16.053" style="s2">The pectoralis minor's not<br />very visible on this picture.</p>
<p begin="00:04:16.053" end="00:04:20.173" style="s2">Deep to the artery we<br />see the subscapularis.</p>
<p begin="00:04:20.173" end="00:04:23.237" style="s2">The needle has now injected<br />on the cranial side</p>
<p begin="00:04:23.237" end="00:04:26.893" style="s2">and is being advanced deep to the artery.</p>
<p begin="00:04:26.893" end="00:04:30.989" style="s2">And you can see the injection<br />there below the artery</p>
<p begin="00:04:30.989" end="00:04:34.710" style="s2">getting local anesthetic<br />around the posterior cord.</p>
<p begin="00:04:34.710" end="00:04:38.037" style="s2">We continued to advance the needle</p>
<p begin="00:04:38.037" end="00:04:41.037" style="s2">so it injects around the medial cord</p>
<p begin="00:04:43.006" end="00:04:46.173" style="s2">on the more caudal side of the artery.</p>