We’re back for yet another exciting edition. This week we’ll be focusing on: 2 topics: 1) “Peripheral” Access, and 2) Splinting Basics.
“Peripheral “ IJ Access
Ever had a patient that was an access nightmare? Multiple attempts by nursing staff have failed and your attempts to gain access through the external jugular (EJ) or US guided brachial and deep brachial were unsuccessful. What do you do next?
Well, there has been some buzz about placing a “peripheral” over-the-needle angiocatheter in the Internal Jugular Vein (IJ).
No one is better suited to access the IJ than EM trained physicians. This technique is US guided and performed under sterile technique.
So When Should You Consider a Peripheral IJ?
- The patient’s disposition is headed toward going home
- Temporary access is needed
- Central venous access is not required.
1) A patient who requires a dose of IV antibiotics before discharge
2) A patient requiring conscious sedation prior to discharge.
3) A patient who needs AED prior to discharge
A standard catheter-over-needle device is placed under US-guidance with sterile probe cover and jelly using an out-of-plane technique. Confirmation is then made with an in-plane technique.
- Time: 2-7 minutes
- No dilation of large vessels
- No guidewire-induced dysrhythmia
A quick temporary line for difficult access. Another tool for your toolbelt.
Questions to Consider
1) Can you use a PIJ to inject contrast for your rule-out pulmonary embolism or to pan-scan for trauma? In the Teismann case study, 1 patient successfully received contrast through the PIJ; however, many institutions may have protocols that will not inject contrast through such a line for the same inherent risks of injecting through an EJ. Consider discussing protocol with your radiologist before using a PIJ to inject contrast.
2) Thus far, the only evidence for PIJ has been based on case studies with 9 patients. As with any procedure, there are risks which should be considered before moving forward.
1) The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter Teismann, Nathan A. et al.Journal of Emergency Medicine , Volume 44 , Issue 1 , 150 – 154
2) Shokoohi H, Boniface K, McCarthy M, Khedir Al-tiae T, Sattarian M, Ding R, Liu YT, Pourmand A, Schoenfeld E, Scott J, Shesser R, Yadav K. Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med. 2013 Feb;61(2):198-203.
The impetus for this post is that it’s something we do every day, but our technique may not be consistent and may be learned more by experiential learning than formally taught.
Additionally, the beauty of FOAM is the plethora of resources available online. There are a ton of instructional videos out there, so if a picture is worth a thousand words, a video certainly is…
Below are some great quick resources worth sharing.
1) EMCAST: http://blog.ercast.org/splint-like-a-pro/
2) EM In 5:
- Immobilize joint above and Below
- Ortho should be consulted for a) open fracture b) angulated or displaced fracture c) neurovascular compromise
- When choosing a splint, a good rule of thumb is ½ the circumference of the extremity being splinted
- Splint in position of function
- Principles of Primary Wound Management. Mortiere. 1996.
- UptoDate, Splinting of musculoskeletal Injuries.