VOTW: Supraclavicular Nerve Block

71 y/o male with PMHx of GERD, presents to the ED via EMS found on floor at bottom of stairwell likely from fall with unknown down time. Patient with bilateral racoon eyes, complaining of right arm pain with right elbow deformity, sling in place. Patient is hard of hearing but patient's family at bedside.

In the first clip we are scanning through to look at the anatomy, this is a sister block to the interscalene and so some of the landmarks are similar with the middle scalene and anterior scalene on either side, but instead of the "stop light" morphology that we see in interscalene block, here we see more of a "bundle of grapes" look. (featuring amazing art from US fellow alumni Dr. Jessie Chen!)

In the 2nd clip we visualize the needle's trajectory as it aims for that supraclavicular bundle. 

Positioning the patient's head to turn to the left as much as possible is important in order to expose the area around the clavicle.

In the 3rd clip we visualize about 10cc of anesthetic being injected around the bundle. Since this was for a quick procedure we used lidocaine 1%. Always remember to calculate the safe amount of anesthetic for each patient you do a nerve block for!

The team was able to reduce the right shoulder successfully!

POCUS Pearls for Supraclavicular Nerve Blocks:

• Indications include upper extremity fractures (distal to mid-humerus), elbow dislocations, forearm lacerations

• Use linear probe positioned transverse just above clavicle; head turned away

• Find artery medial with “bundle of grapes” lateral and visualize the rib deep

• Rib is the safety backstop and visualize the pleura deep and medial

• In-plane approach with needle entering lateral towards medial

• Visualize tip at all times; hydrodissect 1–2 mL before injecting anesthetic

• Inject 10-15 mL for circumferential spread around the bundle

VOTW: ESPecial Block

50 y/o male with PMHx of HTN presents to the ED s/p  fall down stairs today. Patient states that he was walking to work then slipped and fell down a whole flight of stairs, striking the L side of his chest with left lateral chest pain. 

Patient had left posterior and anterior rib fractures of ribs 6-10 with a small pneumothorax and some hemothorax, so the decision was made to do an Erector Spinae Plane Block for pain control.

All the clips were recorded with probe marker towards the patient's head and on the left mid-back of the patient's body.

In the first clip we are looking at the landmarks of the ribs and pleura, then tracking more medially and we see the ribs become the transverse processes

Here we are seeing the "flat" areas of the transverse processes and the hazy pleura beneath. This is where we would aim for the needle to go.

In the second and third clip we see the needle trajectory and we see the needle tip at the transverse process and injecting ropivacaine right at the transverse process and lifting the erector spinae muscle off the TP slightly.

The patient reported improvement in pain and was admitted for monitoring due to his injuries.

POCUS Pearls for Erector Spinae Nerve Blocks

• Use linear or curvilinear probe positioned parasagittal 2–3 cm lateral to midline

• Transverse process (TP) is the goal landmark and it is a flat hyperechoic line + shadow (NOT rib)

• Muscle layers include Trapezius to Rhomboid (upper T-spine) to Erector spinae right above the TP

• Targeting the plane deep to erector spinae / superficial to TP

• Needle visualization in-plane until TP contact

• Use 1–3 mL saline to hydrodissect and confirm plane

• Visualize the fluid spread when the erector spinae “lifts off” TP

• Inject 20–30 mL (adult) and continue looking for spread

VOTW: Eye for an Eye

40 y/o male with no PMHx presents for sudden visual changes in the right eye starting yesterday morning with blurry vision in the inferior visual field of the right eye. States that he was seeing "white bubbles,” and a “wave” that is black with some red discoloration.  Reports that the vision changes worsened acutely with the "dark area" appearing to expand upward. Denies eye pain, trauma, or prior similar episodes. States that he wears glasses at baseline with no other ocular diseases.

In Clip 1 there is a thick bright hyperechoic line that extends from the optic disc, very much tethered to the back of the eye ball, that is the retina that has detached from the back of the eye.

In Clip 2 it shows that the retina does seem attached to the optic disc because you can see the optic nerve sheath in this image.

In both clips you can see that when the patient moves his eye, the retina is mobile but attached to the optic disc/back of the eye. This is concerning for retinal detachment until proven otherwise!

Patient was transferred to outside hospital to Ophthalmology for retinal detachment.

POCUS Pearls for Retinal Detachment Ocular Ultrasound:

• Hyperechoic, thick linear membrane within the vitreous

• Tethered to the optic disc (key distinguishing feature)

• V-shaped, Y-shaped, or funnel-shaped configuration in larger detachments

• Limited mobility with eye movement (moves less than vitreous debris)

• Often described as a “sail” or “curtain” floating in the posterior chamber