Procedure Manual

Vascular Access Procedures

External Jugular IV line Placement

Indications

  • Patients requiring IV medications or fluids when a peripheral line cannot be established
    • In cardiac arrest scenarios attempt intraosseous access first to avoid interference with resuscitation efforts

Contraindications

  • Child with partial airway obstruction (e.g. suspected epiglottitis)– when agitation from performing procedure may worsen respiratory difficulty

Equipment

  • Appropriate tubing or IV lock
  • # 14 - #24 catheter over the needle
  • Antiseptic swab
  • Gauze pad or adhesive bandage
  • Antibiotic ointment
  • Tape or other securing device

Technique

  • Assemble IV solution and tubing
  • Verify correct IV solution and check for clarity and expiration date
  • Identify the external jugular vein on the lateral aspect of the neck
    • Turn the patient's head slightly to the side opposite the insertion site
    • Slight Trendelenburg position may help accentuate the vein
    • Apply light pressure above the clavicle to engorge the external jugular vein

  • Clean the skin with the antiseptic swab
  • Select a site for puncture, preferably as far away as possible from the clavicle in order to avoid accidental lung puncture
  • Once a flash is obtained advance the catheter over the needle and remove the needle while compressing the proximal tip of the catheter to minimize blood loss
  • Connect IV tubing to the catheter, or secure the IV lock to the catheter and flush with appropriate solution (normal saline)
  • Check the IV insertion site occasionally for swelling which may indicate extravasation or loss of patency

Intraosseous Access using the EZ-IO®

Indications:

  • When vascular access is essential in the management of a severely ill adult of child and no other option is readily available
  • For adults, Medical Control approval is necessary unless the patient is in cardiac arrest

Contraindications:

  • The only absolute contraindication is fracture of the tibia or long bones sites for potential intraosseous access
  • Infection over the insertion site (should be avoided but not strictly contraindicated)
  • Relatively contraindicated if other adequate vascular access is readily available

Technique: Tibial Insertion

  • Identify and palpate the tibial tuberosity just below the knee
  • Locate a consistent flat area of bone 2 cm distal and slightly medial to the tibial tuberosity
  • Support the flexed knee by placing a hand or towel under the calf
  • Cleanse the area with a sterilizing solution and perform insertion using aseptic technique
  • Using the EZ-IO® drill insertion device, gently pierce skin until the needle touches bone. Ensure at least one black line is visible on the needle (if not, select larger needle size)
  • Squeeze the trigger while maintaining gentle, steady pressure on the handle
  • Release the trigger when you feel a decrease in resistance (hub may be flush with skin)
    • If properly placed, the needle should stand up from the bone without assistance
  • Remove the inner trocar and use a syringe to aspirate bone marrow
    • Obtaining marrow confirms placement
  • If marrow does not return when aspirated, flush with 5-10 ml of Normal Saline
    • Significant resistance or extravasation suggests improper placement
    • If flow is good, and no extravasation is seen, attach IV tubing and secure in place

Technique: Humeral Head Insertion

  • This site is only to be used on adult cardiac arrest patients
  • The humerus is most easily palpated at the insertion point for the deltoid muscle, between the bicep and tricep muscles
    • This point is approximately mid-way along the length of the arm
    • Palpation of the bone requires firm pressure due to overlying structures
  • The surgical neck can be located by palpating up the length of the humerus until you feel a "notch" or "groove"

  • The appropriate insertion site is approximately 1cm above the surgical neck for most adults
  • Cleanse the area with a sterilizing solution and perform insertion using aseptic technique
  • Using the EZ-IO® drill insertion device, place the needle tip at the selected insertion site, keeping the needle perpendicular to the skin

  • Push the needle through the skin and make contact with the bone (ensure at least one black line is visible)
  • When ready press the trigger while maintaining gentle steady pressure on the handle
  • Once the needle hub has contacted the shin release the trigger
    • If properly placed, the needle should stand up from the bone without assistance
  • Remove the inner trocar and use a syringe to aspirate bone marrow
    • Obtaining marrow confirms placement
  • If marrow does not return when aspirated, flush with 5-10 ml of Normal Saline
    • Significant resistance or extravasation suggests improper placement
    • If flow is good, and no extravasation is seen, attach IV tubing and secure in place

Complications:

  • Extravasation of fluid or caustic medications
  • Pain, fracture, hematoma, growth plate injury
  • Compartment syndrome
  • Osteomyelitis
  • Cellulitis at the insertion site

Peripheral IV line Placement

Indications

  • Patients requiring IV medications or fluids
  • Patients with any potential for deterioration (e.g. seizures, altered mentation, trauma, chest pain, difficulty breathing)

Contraindications

  • Child with partial airway obstruction (e.g. suspected epiglottitis)– when agitation from performing procedure may worsen respiratory difficulty

Equipment

  • Appropriate tubing or IV lock
  • # 14 - #24 catheter over the needle
  • Venous tourniquet
  • Antiseptic swab
  • Gauze pad or adhesive bandage
  • Antibiotic ointment
  • Tape or other securing device

Technique

  • Assemble IV solution and tubing
  • Verify correct IV solution and check for clarity and expiration date
  • Place the tourniquet around the patient’s arm proximal to the IV site
  • Identify the most appropriate venous puncture site
  • Clean the skin with the antiseptic swab in an increasing sized concentric circle and follow it with an alcohol swab
  • Stabilize the vein distally and enter the skin with the bevel of the needle facing upward
  • Once a flash is obtained advance the catheter over the needle and remove the needle while compressing the proximal tip of the catheter to minimize blood loss
  • Remove the tourniquet
  • Connect IV tubing to the catheter, or secure the IV lock to the catheter and flush with appropriate solution (normal saline)
  • Check the IV insertion site occasionally for swelling which may indicate extravasation or loss of patency