Supplies

a. High frequency (linear/vascular) transducer

b. Sterile ultrasound probe cover (or tegaderm)

c. Sterile gloves

d. Chlorhexadine or alcohol swab

e. 30cc long-acting anesthetic (i.e. 0.25% bupivacaine) for block, 1-2cc short-acting anesthetic (i.e. lidocaine) to numb skin for procedure

f. 22 G nerve block or spinal needle; IV extension tubing if using spinal needle

g. 30cc syringe for block, insulin syringe for skin

Technique

a. Position patient in supine or lateral decubitus position (injured side facing up).

b. Sterilize skin. Inject wheal of lidocaine where needle will enter skin.

c. Start with probe in non-dominant hand, lateral to the nipple in transverse orientation.

d. Find the serratus anterior muscle overlying the ribs in the lateral chest wall.

e. Use the in-plane technique, staying relatively shallow relative to the skin, advance the needle with dominant hand.

f. Identify the pleural line prior to inserting the needle.

g. Aim your needle toward a bright, white rib. You will feel a pop through the fascia.

h. Connect tubing to needle and syringe and perform a small test push (2-3cc) to confirm placement between the serratus anterior and latissimus dorsi. If the two separate freely, inject remaining anesthetic. (It is helpful to have a helper push the anesthetic).

Jordan Becker, MD, MS
PGY-2, Emergency Medicine resident
Michael Kosofsky, MS4
Lewis Katz School of Medicine at Temple University