The Supraclavicular Subclavian


    The Supraclavicular Subclavian

    Traditionally, central line placement in the subclavian vein (SCV) involves a landmark-based approach in which the needle is guided under the clavicle. For the U/S lovers, there is an alternative approach to the subclavian in which the sono may be utilized: the supraclavicular subclavian.

    Anatomy: The goal is to cannulate the SCV just lateral to clavicular head of the sternocleidomastoid muscle. The right SCV is preferred as it forms a straighter angle with internal jugular, and thus a shorter path to the superior vena cava. Furthermore, the thoracic duct, a structure you would prefer not to damage, drains into the the left SCV. You aim just lateral to where the ext jugular vein joins the SCV.

    Technique: As always, perform standard sterile and needle precautions to minimize harm to yourself and to the patient. With the linear probe, start by visualizing the internal jugular and following it inferiorly until your ultrasound abuts the clavicle. You should see the confluence of the IJV and SCV forming the brachiocelphic vein. You may angle posteriorly to visualize the pulsating subclavian artery to confirm your position (figure 1a). Then angle anteriorly to identify where the external jugular enters the SCV for the ideal location for cannulation (see figure 1b). Reposition, and then enter the skin slowly and follow your needle tip with the in-plane technique (this should be easier than most standard in-plane tracting of the needle as your needle and U/S probe are pushed against the clavicle. From there you may use your standard confirmation of adequate placement techniques (eg, manometry, aspiration, visualization of the guide wire in the SCV). Get the post-placement x-ray to r/o ptx and confirm placement.


    1. Visualization of the anatomy may be a challenge in the pts with a large BMI or short neck.
    2. The technique relies on use of the in-plane guidance of the needle in the subclavian, a technique that we are less familiar with. It seems like PTX risk may be less given the use of U/S, but keep in mind that your are pointing your needle down towards the lung (unlike the infraclavicular approach) and if you lose sight of your needle tip, then you can easily drop a lung.


    Consider the supraclavicular subclavian when your go to IJ isn’t an option (abnormal neck anatomy, IJV thrombosis, presence of a c-collar).

    Thank you Ryan for lending me your beautiful veins!!!


    1. Mallin M, Louis H, Madsen T. A novel technique for ultrasound-guided supraclavicular subclavian cannulation. Am J Emerg Med. 2010;28:966-969.
    2. Leiu, C, et al. Using the Supraclavicular Approach to Ultrasound-Guided Subclavian Vein Cannulation. ACEP Now. Available at: Accessed Aug 2018.
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more