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Am J Emerg Med. 2017 May;35(5):773-777. doi: 10.1016/j.ajem.2017.01.028. Epub 2017 Jan 15.

Ultrasound-guided retroclavicular approach infraclavicular brachial plexus block for upper extremity emergency procedures.

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Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, United States. Electronic address:
Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, United States; Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States.


The America Society of Anesthesiology guidelines recommend multimodal analgesia that combines regional anesthetic techniques with pharmacotherapy to improve peri-procedural pain management and reduce opioid related complications. Commonly performed emergency procedures of the upper extremity such as fracture and dislocation reduction, wound debridement, and abscess incision and drainage are ideal candidates for ultrasound-guided (USG) regional anesthesia of the brachial plexus. However, adoption of regional anesthesia by emergency practitioners has been limited by concerns for potential complications and perceived technical difficulty. The Retroclavicular Approach to The Infraclavicular Region (RAPTIR) is a newly described USG brachial plexus block technique that optimizes sonographic needle visualization as a means of making regional anesthesia of the upper extremity safer and easier to perform. With RAPTIR a single well-visualized injection distant from key anatomic neck and thorax structures provides extensive upper extremity anesthesia, likely reducing the risk of complications such as diaphragm paralysis, central block, nerve injury, vascular puncture, and pneumothorax. Additionally, patient positioning for RAPTIR is well suited for the awake, acutely injured ED patient as the upper extremity remains adducted in a position of comfort at the patient's side. Thus, RAPTIR is a potentially ideal combination of infraclavicular targeting, excellent needle visualization, single injection, safety, comprehensive upper extremity analgesia, rapid performance, and comfortable patient positioning. Herein we present the first description of the RAPTIR utilized in the ED. Our initial experience suggests this is a promising new technique for brachial plexus regional anesthesia in the ED setting.


Emergency services; Nerve block; Pain management; Ultrasonography

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