These slides have been selected from an "ask the expert" session that Dr Amit Pawa gave at the Dublin Convention Centre on 13th September 2018 for the ESRA (European Society of Regional Anaesthesia) 2018 annual meeting. These slides are shared to anyone with the link - please only practice techniques described if you are suitably trained to do so. Many thanks

1. Ask The Expert
Session
Retroclavicular APproach To
the Infraclavicular Region
Dr Amit Pawa
@amit_pawa #ESRA2018

2. Guy’s
Hospital
St Thomas’
Hospital

3. Faculty Disclosure
Company Name
Honoraria/
Expenses
Consulting/
Advisory Board
Funded
Research
Royalties/
Patent
Stock
Options
Ownership/
Equity
Position
Employee
Other
(please specify)
GE Healthcare x
B Braun Medical Ltd x
Medaphor x
Regional Anaesthesia – UK President
No, nothing to disclose
✔ Yes, please specify:

4. Expert - Definition
Invitation to speak
Dr Ki Jinn Chin - Toronto - Canada

5. IFCB =
Infraclavicular Block
Anatomy animations from Essential
Anatomy 5 - 3D4Medical

6. Why Talk About this?
IFCB popular - elbow/forearm/hand surgery
IFCB - good site for nerve catheters
BUT…
Needle angle/visibility
Blood Vessels
@amit_pawa

7. Session Format
Background
Evidence
My Opinion
My Experience
We Discuss - You Decide!
@amit_pawa

8. Infraclavicular
Current US Guided Approaches
ClassicalRetroclavicular Costoclavicular
@amit_pawa

9. @amit_pawa

10. Classical IFCB

11. Structures to Identify
Axillary Artery & Vein
Lateral,
Posterior,
Medial Cords
Inject LA “around” artery
VAL
P
M
@amit_pawa

12. Infraclavicular
Sonoanatomy
Template
@amit_pawa

13. ©
- Amit Pawa

14. Cords rotate around Artery

15. Cephalad Caudad
@amit_pawa

16. Needle Insertion View of
Classical IFCB
(BELOW clavicle)

17. @amit_pawa

18. Vessels
Clav
@amit_pawa

19. ©
- Amit Pawa
Poor Needle Visibility
@amit_pawa

20. POOR NEEDLE VISIBILITY
@amit_pawa

21. Issues with Classical IFCB
Steep insertion angle
Poor needle visibility
Vessels in needle path
Narrow space between clavicle & probe
@amit_pawa

22. If only there was another way…
@amit_pawa

23. Evolution of the RAPTIR
Landmark PNS Classic US RAPTIR
@amit_pawa

24. Evolution of RAPTIR
1. Hebbard & Royse 2007
“US-Guided posterior approach to
infraclavicular brachial plexus”
Improved needle visibility
@amit_pawa

25. Hebbard P, Royse C. Ultrasound guided posterior
approach to the infraclavicular brachial plexus.
Anaesthesia. 2007;62:539
@amit_pawa

26. Hebbard P, Royse C. Ultrasound guided posterior
approach to the infraclavicular brachial plexus.
Anaesthesia. 2007;62:539
ound guided posterior
ach to the
avicular brachial plexus
conventional ultrasound guided
hes to the infraclavicular brach-
s the needle is acutely angled to
sound beam, making needle tip
tion difficult. This limitation
overcome by changing the
n point so that the needle passes
Pectoralis
Major
Pectoralis
Major
Pleura
Rib
Rib
Subscapularis
Supraspinatus
Scapula
Trapezius
Clavicle
Deltoid
N
N
N
A
V
with
am.
to
ted,
in
r, a
icle, or a more medial approach may be
used.
ment relative to neurovascular struc-
tures. The block needle is also more
easily directed posterior to the artery
than when using the conventional
approach.
Further information on this and other
new ultrasound guided approaches may
be found at www.heartweb.com.au
P. Hebbard1
and C. Royse2
1 Consultant Anaesthetist,
North-east Health, Wangaratta,
2 Associate Professor, Anaesthesia and
Pain Management Unit, Department of
Pharmacology, University of
Melbourne, and Department of
Anaesthesia and Pain Medicine, Royal
Melbourne Hospital, Melbourne,@amit_pawa

27. Evolution of RAPTIR
2. 1st Clinical Feasibility Study
Charbonneau et al 2015
“US-Guided Retroclavicular Block”
@amit_pawa

28. Retroclav block with 40 mls LA
48/50 pts - sucessful surgery
2 block failures
2 paraesthesias, 1 arterial puncture
No PTX
Slow onset MC nerve block
e foll
search assist
r satisfaction with t
(0 = totally unsatisfied,
tioned about possible complicati
hematoma, signs of infection, dyspnea).
ual the depth of the axillary
spond to the clavicle
icine
Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015 Ultrasound
Charbonneau J, Fréchette Y, Sansoucy Y, Echave P. The
ultrasound-guided retroclavicular block: a prospective
feasibility study. Reg Anesth Pain Med. 2015;40:605–609.
@amit_pawa

29. Retroclav block with 40 mls LA
48/50 pts - sucessful surgery
2 block failures
2 paraesthesias, 1 arterial puncture
No PTX
Slow onset MC nerve block
Charbonneau J, Fréchette Y, Sansoucy Y, Echave P. The
ultrasound-guided retroclavicular block: a prospective
feasibility study. Reg Anesth Pain Med. 2015;40:605–609.
@amit_pawa

30. Evolution of RAPTIR
3. Name Change & Additional benefits
Sutton, Bullock & Gadsden 2015
“Retroclavicular Approach to the
Infraclavicular Region”
@amit_pawa

31. @amit_pawa
Retroclavicular APproach To Infraclavular Region
(RAPTIR)
Avoid Cephalic Vein & Acromial Branch of TAA
Lateral cord trauma
Catheters
Arm ADducted
Re-direct for lateral cord (MCN)
Sutton EM, Bullock WM, Gadsden J. The retroclavicular
brachial plexus block: additional advantages. Reg Anesth
Pain Med. 2015;40:733–734.

32. @amit_pawa
Retroclavicular APproach To Infraclavular Region
(RAPTIR)
Avoid Cephalic Vein & Acromial Branch of TAA
Lateral cord trauma
Catheters
Arm ADducted
Re-direct for lateral cord (MCN)
Sutton EM, Bullock WM, Gadsden J. The retroclavicular
brachial plexus block: additional advantages. Reg Anesth
Pain Med. 2015;40:733–734.
:
0.
8.

33. But was this new?..
l.
and high
injury and
sth Pain
Chan V,
motor
paresthesia
by
2006;31:
practice.
145–1162.
18 y 19
“Those Who Don't
Remember the Past Are
Condemned to Relive It”
Dr. Alon P. Winnie and
his Subclavian
Perivascular Technique
Accepted for publication: February 17, 2016.
To the Editor:
harbonneau et al1
present an interest-
r on both sides of the nerve (red arrows) corresponds
by the blocking needle. Note that the needle has been
First, we highlight that the aim of this
technique is to direct the needle caudally to
access the proximal infraclavicular space.
Thus, the point of administration of local
anesthetic is performed at the first por-
tion of the axillary artery. However, this
approach involves an ultrasound “dark
zone” generated by the clavicle acoustic
shadow. This incident, in our opinion, is
a serious concern because it hinders the
visualization of the tip of the needle. Re-
garding this fact, we would like to recall
the similitude with the recently pub-
lished technique by our group named
“costoclavicular block.”3,4
In our view,
a better tracing of the entire needle can
be obtained with our approach.
In the retroclavicular block,1
also
named posteriorapproach to infraclavicular
brachial plexus by Hebbard and Royse,2
the
Rolando Muñoz, MD
Viviana Mojica, MD
Manuel Doreste, MD
Faculty of Medicine
University of Barcelona
Barcelona, Spain
Xavier Sala-Blanch, MD
Faculty of Medicine
University of Barcelona
and Department of Anesthesiology
Hospital Clinic
Barcelona, Spain
The authorsdeclare noconflictof interest.
REFERENCES
1. Charbonneau J, Fréchette Y, Sansoucy Y, Echave
P. The ultrasound-guided retroclavicular block: a
prospective feasibility study. Reg Anesth Pain
2) Rabb
but the direc
humans is de
better, human
suitable optio
of rabbit skin
Such data (ra
were not prov
3) The
freshly healed
a tattoo is no
cording to Lea
ink particles a
cells resemblin
to fibroblasts.”
croscopic pic
skin is a lim
women gene
pregnancy. T
concerns ma
Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016
First, we highlight that the aim of this Rolando Muñoz, M
Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016
@amit_pawa

34. Evolution of RAPTIR
Winnie AP, Collins VJ. The subclavian perivascular
technique of brachial plexus anesthesia.
Anesthesiology. 1964;25:353–363

35. Evolution of RAPTIR
Winnie AP, Collins VJ. The subclavian perivascular
technique of brachial plexus anesthesia.
Anesthesiology. 1964;25:353–363

36. Seeing things the
RAPTIR Way
@amit_pawa

37. ©
- Amit Pawa
Excellent Needle Visibility
@amit_pawa

38. RAPTIR VESSELS
Caudad Cephalad
@amit_pawa

39. What about
Musculocutaneous Sparing?
@amit_pawa

40. Extra-Raptir Move
@amit_pawa

41. Are they any Risks
with RAPTIR?
@amit_pawa

42. “Blind” Zone
@amit_pawa

43. Structures At Risk
Suprascapular Nerve
Suprascapular Artery & Vein
Posterior Cord
Pleura
@amit_pawa

44. @amit_pawa

45. 3 Cadavers - bilateral blocks
RAPTIR Needle & Catheter Insertions
What structures contacted/pierced?
Trapezius punctured in all dissections
Downloadedfromhttps://journals.lww.com/rapmbytfVAtQeu7CaqDjyZk4Ty25tWfW5Eu8+Lugl9xkjVmMCH9UQIIQ1Lwy8XsV+J4jWRPKvuKK0bg7yuoV866j3HHuWqOt/5GtRIc5vKcIbu
A Cadaver Study Investigating Structures Encountered by the
Needle During a Retroclavicular Approach to Infraclavicular
Brachial Plexus Block
Sushil F. Sancheti, MD, FRCPC, Vishal Uppal, DA, EDRA, FRCA, Robert Sandeski,
M. Kwesi Kwofie, MD, FRCPC, and Jennifer J. Szerb, MD, FRCPC
Background and Objectives: Retroclavicular block is designed to
overcome the negative aspects of the commonly utilized ultrasound-
guided parasagittal approach to the infraclavicular block. However, this ap-
proach necessitates the needle traversing an area posterior to the clavicle in-
accessible to ultrasound wave conduction. This study sought to document
the structures vulnerable to needle injury during a retroclavicular block.
Methods: A Tuohy needle was inserted using a retroclavicular approach
to the infraclavicular block in 3 lightly embalmed cadavers followed by a
catheter insertion 4 cm beyond the needle tip. The process was repeated
on the contralateral side. With the needle and catheter in position, the ca-
davers were dissected and photographed.
Results: In 4 of the 6 dissections, the needle was directly touching the
suprascapular nerve deep to the clavicle. In the remaining 2 dissections,
the suprascapular nerve was within 2 cm of the needle. In 1 dissection,
the suprascapular vein was indented, behind the clavicle. The trapezius
was the only muscle layer traversed by the needle in all dissections. In 3
of the 6 dissections, the catheter penetrated the posterior cord. In the re-
maining 3, the catheter threaded along the neurovascular bundle.
Conclusions: The suprascapular nerve is consistently in the path of
the block needle posterior to the clavicle. This raises the possibility of
risk of injury to the suprascapular nerve when using this approach to the
brachial plexus. Vascular injury is also possible deep to the clavicle, and
because of the noncompressible location, caution is advised in patients
with disordered coagulation.
(Reg Anesth Pain Med 2018;43: 00–00)
nfraclavicular brachial plexus block is useful approach to pro-
surgery.1
The commonly utilized ultrasound-guided parasagittal
method has several disadvantages: needle visualization can be dif-
ficult because of its steep insertion angle, the lateral cord is vulner-
able to injury, and the acromial branch of the thoracoacromial artery
is prone to puncture.2,3
In 2007, Hebbard and Royse4
published an
ultrasound-guided posterior approach to the infraclavicular bra-
chial plexus designed to overcome these limitations. With this ap-
proach, the needle is inserted posterior to the clavicle and passes
underneath it in a cephalad-to-caudad direction. This allows ex-
cellent needle visualization as the ultrasound beam is perpendicu-
lar to the shaft of the needle. Further, the needle trajectory is posterior
to the lateral cord and acromial artery and therefore might reduce the
chance of direct needle trauma to these structures during the proce-
dure.3
Charbonneau and colleagues5
showed the technique is quick
and reliable. Subsequently, Ozturk and Kavakli6
replicated these find-
ings and found this “retroclavicular approach” is associated with
better needle tip and shaft visibility, reduced performance time,
and fewer paresthesias than with the conventional approach.
However, there is one significant disadvantage to the retro-
clavicular approach: the bony clavicle causes acoustic impedance,
creating a “blind spot” that the needle must traverse before
appearing on the ultrasound image. Structures behind the clavicle
cannot be visualized and therefore are at risk of damage. Pre-
existing anatomical descriptions of the area indicate that the
subclavius muscle, supraspinatus muscle, and subscapularis muscle
may be encountered during needle insertion, and the suprascapular
nerve and its attendant artery and vein may be vulnerable to injury.4
To our knowledge, there is no published cadaver dissection describ-
ing the structures that lie in the needle's path while using the
BRIEF TECHNICAL REPORT
Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized repro
@amit_pawa

46. Downloadedfromhttps://journals.lww.com/rapmbytfVAtQeu7CaqDjyZk4Ty25tWfW5Eu8+Lugl9xkjVmMCH9UQIIQ1Lwy8XsV+J4jWRPKvuKK0bg7yuoV866j3HHuWqOt/5GtRIc5vKcIbu
A Cadaver Study Investigating Structures Encountered by the
Needle During a Retroclavicular Approach to Infraclavicular
Brachial Plexus Block
Sushil F. Sancheti, MD, FRCPC, Vishal Uppal, DA, EDRA, FRCA, Robert Sandeski,
M. Kwesi Kwofie, MD, FRCPC, and Jennifer J. Szerb, MD, FRCPC
Background and Objectives: Retroclavicular block is designed to
overcome the negative aspects of the commonly utilized ultrasound-
guided parasagittal approach to the infraclavicular block. However, this ap-
proach necessitates the needle traversing an area posterior to the clavicle in-
accessible to ultrasound wave conduction. This study sought to document
the structures vulnerable to needle injury during a retroclavicular block.
Methods: A Tuohy needle was inserted using a retroclavicular approach
to the infraclavicular block in 3 lightly embalmed cadavers followed by a
catheter insertion 4 cm beyond the needle tip. The process was repeated
on the contralateral side. With the needle and catheter in position, the ca-
davers were dissected and photographed.
Results: In 4 of the 6 dissections, the needle was directly touching the
suprascapular nerve deep to the clavicle. In the remaining 2 dissections,
the suprascapular nerve was within 2 cm of the needle. In 1 dissection,
the suprascapular vein was indented, behind the clavicle. The trapezius
was the only muscle layer traversed by the needle in all dissections. In 3
of the 6 dissections, the catheter penetrated the posterior cord. In the re-
maining 3, the catheter threaded along the neurovascular bundle.
Conclusions: The suprascapular nerve is consistently in the path of
the block needle posterior to the clavicle. This raises the possibility of
risk of injury to the suprascapular nerve when using this approach to the
brachial plexus. Vascular injury is also possible deep to the clavicle, and
because of the noncompressible location, caution is advised in patients
with disordered coagulation.
(Reg Anesth Pain Med 2018;43: 00–00)
nfraclavicular brachial plexus block is useful approach to pro-
surgery.1
The commonly utilized ultrasound-guided parasagittal
method has several disadvantages: needle visualization can be dif-
ficult because of its steep insertion angle, the lateral cord is vulner-
able to injury, and the acromial branch of the thoracoacromial artery
is prone to puncture.2,3
In 2007, Hebbard and Royse4
published an
ultrasound-guided posterior approach to the infraclavicular bra-
chial plexus designed to overcome these limitations. With this ap-
proach, the needle is inserted posterior to the clavicle and passes
underneath it in a cephalad-to-caudad direction. This allows ex-
cellent needle visualization as the ultrasound beam is perpendicu-
lar to the shaft of the needle. Further, the needle trajectory is posterior
to the lateral cord and acromial artery and therefore might reduce the
chance of direct needle trauma to these structures during the proce-
dure.3
Charbonneau and colleagues5
showed the technique is quick
and reliable. Subsequently, Ozturk and Kavakli6
replicated these find-
ings and found this “retroclavicular approach” is associated with
better needle tip and shaft visibility, reduced performance time,
and fewer paresthesias than with the conventional approach.
However, there is one significant disadvantage to the retro-
clavicular approach: the bony clavicle causes acoustic impedance,
creating a “blind spot” that the needle must traverse before
appearing on the ultrasound image. Structures behind the clavicle
cannot be visualized and therefore are at risk of damage. Pre-
existing anatomical descriptions of the area indicate that the
subclavius muscle, supraspinatus muscle, and subscapularis muscle
may be encountered during needle insertion, and the suprascapular
nerve and its attendant artery and vein may be vulnerable to injury.4
To our knowledge, there is no published cadaver dissection describ-
ing the structures that lie in the needle's path while using the
BRIEF TECHNICAL REPORT
Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized repro
Ceph
Lateral
@amit_pawa

47. Downloadedfromhttps://journals.lww.com/rapmbytfVAtQeu7CaqDjyZk4Ty25tWfW5Eu8+Lugl9xkjVmMCH9UQIIQ1Lwy8XsV+J4jWRPKvuKK0bg7yuoV866j3HHuWqOt/5GtRIc5vKcIbu
A Cadaver Study Investigating Structures Encountered by the
Needle During a Retroclavicular Approach to Infraclavicular
Brachial Plexus Block
Sushil F. Sancheti, MD, FRCPC, Vishal Uppal, DA, EDRA, FRCA, Robert Sandeski,
M. Kwesi Kwofie, MD, FRCPC, and Jennifer J. Szerb, MD, FRCPC
Background and Objectives: Retroclavicular block is designed to
overcome the negative aspects of the commonly utilized ultrasound-
guided parasagittal approach to the infraclavicular block. However, this ap-
proach necessitates the needle traversing an area posterior to the clavicle in-
accessible to ultrasound wave conduction. This study sought to document
the structures vulnerable to needle injury during a retroclavicular block.
Methods: A Tuohy needle was inserted using a retroclavicular approach
to the infraclavicular block in 3 lightly embalmed cadavers followed by a
catheter insertion 4 cm beyond the needle tip. The process was repeated
on the contralateral side. With the needle and catheter in position, the ca-
davers were dissected and photographed.
Results: In 4 of the 6 dissections, the needle was directly touching the
suprascapular nerve deep to the clavicle. In the remaining 2 dissections,
the suprascapular nerve was within 2 cm of the needle. In 1 dissection,
the suprascapular vein was indented, behind the clavicle. The trapezius
was the only muscle layer traversed by the needle in all dissections. In 3
of the 6 dissections, the catheter penetrated the posterior cord. In the re-
maining 3, the catheter threaded along the neurovascular bundle.
Conclusions: The suprascapular nerve is consistently in the path of
the block needle posterior to the clavicle. This raises the possibility of
risk of injury to the suprascapular nerve when using this approach to the
brachial plexus. Vascular injury is also possible deep to the clavicle, and
because of the noncompressible location, caution is advised in patients
with disordered coagulation.
(Reg Anesth Pain Med 2018;43: 00–00)
nfraclavicular brachial plexus block is useful approach to pro-
surgery.1
The commonly utilized ultrasound-guided parasagittal
method has several disadvantages: needle visualization can be dif-
ficult because of its steep insertion angle, the lateral cord is vulner-
able to injury, and the acromial branch of the thoracoacromial artery
is prone to puncture.2,3
In 2007, Hebbard and Royse4
published an
ultrasound-guided posterior approach to the infraclavicular bra-
chial plexus designed to overcome these limitations. With this ap-
proach, the needle is inserted posterior to the clavicle and passes
underneath it in a cephalad-to-caudad direction. This allows ex-
cellent needle visualization as the ultrasound beam is perpendicu-
lar to the shaft of the needle. Further, the needle trajectory is posterior
to the lateral cord and acromial artery and therefore might reduce the
chance of direct needle trauma to these structures during the proce-
dure.3
Charbonneau and colleagues5
showed the technique is quick
and reliable. Subsequently, Ozturk and Kavakli6
replicated these find-
ings and found this “retroclavicular approach” is associated with
better needle tip and shaft visibility, reduced performance time,
and fewer paresthesias than with the conventional approach.
However, there is one significant disadvantage to the retro-
clavicular approach: the bony clavicle causes acoustic impedance,
creating a “blind spot” that the needle must traverse before
appearing on the ultrasound image. Structures behind the clavicle
cannot be visualized and therefore are at risk of damage. Pre-
existing anatomical descriptions of the area indicate that the
subclavius muscle, supraspinatus muscle, and subscapularis muscle
may be encountered during needle insertion, and the suprascapular
nerve and its attendant artery and vein may be vulnerable to injury.4
To our knowledge, there is no published cadaver dissection describ-
ing the structures that lie in the needle's path while using the
BRIEF TECHNICAL REPORT
Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized repro
Ceph
Lateral
Structure Number of cadavers
SSN & Needle CONTACT 4/6
SSN within 2cm of Needle 6/6
SSV & Needle CONTACT 1/6
Posterior Cord
PENETRATION
(catheter)
3/6
@amit_pawa

48. Any RAPTIR
Evidence?
@amit_pawa

49. @amit_pawa
100 patients - US coracoid vs RAPTIR
Compare needle tip & shaft visibility
Lots of secondary outcomes
(Needle passes/success/patient satisfaction)
Kavut Ozturk N, Kavakli AS. Comparison of the coracoid and
retroclavicular approaches for ultrasound-guided
infraclavicular brachial plexus block. J Anesth. 2017;31:572–578.

50. Kavut Ozturk N, Kavakli AS. Comparison of the coracoid and
retroclavicular approaches for ultrasound-guided
infraclavicular brachial plexus block. J Anesth. 2017;31:572–578.
Parameter Coracoid RAPTIR
Needle tip Visibility
Needle shaft visibility
Needle passes
Paraesthesia
Block Time
Sensory & Motor Block

51. Tips for RAPTIR Success
@amit_pawa

52. 1. Tips for RAPTIR Success
ADduct arm & Towel under shoulder
Scan from medial to Deltopectoral groove
Rotate probe towards axilla
Needle insertion 2cm above clavicle
Travel behind clavicle, parallel to bed, directed towards axilla
American Journal of Emergency Medicine
journal homepage: www.elsevier.com
Ultrasound-guided retroclavicular approach infraclavicular brachial plexus block for
upper extremity emergency procedures
Josh Luftig PAa,
, Daniel Mantuani MDa, b
, Andrew A. Herring MDa, b
, Arun Nagdev, MDa, b
a
Department of Emergency Medicine, Highland Hospital—Alameda Health System, Oakland, CA, United States
b
Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
A R T I C L E I N F O
Article history:
Received 3 December 2016
Received in revised form 13 January
2017
Accepted 14 January 2017
Available online xxx
Keywords:
Pain management
Nerve block
Ultrasonography
Emergency services
A B S T R A C T
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 Re-
gion (RAPTIR) is a newly described USG brachial plexus block technique that optimizes sonographic needle visualiza-
tion 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 anes-
thesia, likely reducing the risk of complications such as diaphragm paralysis, central block, nerve injury, vascular punc-
ture, 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 poten-
rief Report
American Journal of Emergency Medicine 35 (2017) 773–777
Contents lists available at ScienceDirect
American Journal of Emergency Med
journal homepage: www.elsevier.com/locate/a

53. Courtesy of
Josh Luftig
@BenBott

54. Courtesy of
Josh Luftig
@BenBott

55. 2. Tips for RAPTIR Success
Tips & tricks to improve the safety of the retroclavicular
brachial plexus block. Uppal V, Kalagara HKP, Sondekoppam RV.
The American Journal of Emergency Medicine. 36(6) 1107-1108
Pre-procedure scan
Mark needle insertion
Hold needle on clavicle
Position needle tip at caudal
edge of clavicle
icle as shown in Fig. 1. The needle is held by the shaft at the marked en
point which gives the user the approximate length the needle will trav

56. 2. Tips for RAPTIR Success
Tips & tricks to improve the safety of the retroclavicular
brachial plexus block. Uppal V, Kalagara HKP, Sondekoppam RV.
The American Journal of Emergency Medicine. 36(6) 1107-1108
Insert needle to saftey distance
Identify tip as emerges from
clavicle
@amit_pawa

57. 2. Tips for RAPTIR Success
Tips & tricks to improve the safety of the retroclavicular
brachial plexus block. Uppal V, Kalagara HKP, Sondekoppam RV.
The American Journal of Emergency Medicine. 36(6) 1107-1108
-
-
g
al
].
e
s
e
e
d
g
e
1107of Emergency Medicine 36 (2018) 1098–1120
5-6-7 Technique
12
6
39
57
1
2
48
10
11
25% LA
@amit_pawa

58. 2. Tips for RAPTIR Success
Tips & tricks to improve the safety of the retroclavicular
brachial plexus block. Uppal V, Kalagara HKP, Sondekoppam RV.
The American Journal of Emergency Medicine. 36(6) 1107-1108
-
-
g
al
].
e
s
e
e
d
g
e
1107of Emergency Medicine 36 (2018) 1098–1120
5-6-7 Technique
12
6
39
57
1
2
48
10
11
5’o’clock 25% - LA
6’o’clock 50% - LA
7’o’clock 25% - LA
@amit_pawa

59. Tricky RAPTIRS
Thick pectoral region (Big PECS)
Deformed clavicle (#)
“Full” supraclavicular fossa
Short neck
Courtesy @jeffgadsden@amit_pawa

60. @amit_pawa

61. Why So Sceptical?
@amit_pawa

62. Pawa-RAPTIR Experience
@amit_pawa
Chanceofperforming
block(%)
Time (Months)
100
0 3618
2015
“No Way”
“This is SO Cool!”
- The Gadsden-Effect
“Dude - Where is the needle?”
- The Reality Check
“When Needed”
- Selected
Implementation

63. My First Error
@amit_pawa
Classical &
Retroclavicular
APproach !

64. @amit_pawa
One Suggestion
Credit for concept
Dr Stuart Grant
@galusweegie

65. 1. Needle above clavicle -
observe & avoid SSN
@amit_pawa
One Suggestion
Credit for concept
Dr Stuart Grant
@galusweegie

66. 1. Needle above clavicle -
observe & avoid SSN
@amit_pawa
2.Move Probe to IFCB
area
3. Advance towards
Posterior cord
One Suggestion
Credit for concept
Dr Stuart Grant
@galusweegie

67. My Opinion
RAPTIR has a role
Still a Fan of Classical IFCB!
@amit_pawa

68. RAPTIR Summary
“Classical IFCB” can be challenging
A retroclavicular approach (RAPTIR) exists
RAPTIR has potential advantages
RAPTIR is not without risk
RAPTIR is not suitable for everyone
@amit_pawa

69. Over to You