Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!
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EM procedures
Scott Weingart’s approach on how to safely place central lines. These videos serve as reminder on how to acquire central access with fully sterile precautions https://emcrit.org/central-lines/
Have a patient with a serious hand injury? Want to block all of the nerves of the hand with more confidence? See Jacob Avila’s approach to US guided hand block that takes you away from the hand and into the forearm where you can minimize damage to “accidental bystanders” http://blog.5minsono.com/hand_block
While the traditional “blind” ulnar nerve block may have worked, look at this resource on how to maximize your success with an US guided approach and change the site of needly entry https://www.aliem.com/2016/trick-of-the-trade
Two links on difficult airways from the two world renowned experts…one on how to deal with massive fluids in the airway, the other on tips in dealing with the awake intubation
The importance of intravenous (IV) access is something seared in the mind of every practicing emergency department physician. Over the years, central intravenous access for difficult IV access has been obviated by the intraosseous drill and line. Furthermore, we just see and do less central IV lines. The likely reasons for this are that running vasopressors in peripheral intravenous (IV) lines is becoming more accepted as well as the increased time associated with placing a fully sterile central line (draping, etc.) as well as the risks of the over-the-wire procedure (infection, deep vein thrombosis, cardiac arrhythmias).
Enter the internal jugular vein catheterization using a peripheral IV catheter1, which is placed under a limited sterile environment. Is the 5 minutes to establish access that “easy” when peripheral access and external jugular catheterization has failed?
The materials required:
US machine with high-frequency linear transducer probe
Chlorhexidine swab
4.8-cm, 18-gauge single lumen catheter
Two bio-occlusive adherent dressings
Sterile ultrasound jelly
A loop catheter extension
A saline flush
Figure 1. Visual diagram of required materials for the “easy IJ”, adapted from Moayedi et al. (2016).
The steps:
Place your patient in the Trendelenburg position or instruct them to perform a Valsalva maneuver
The needle is inserted into the skin at approximately 45 degrees
Ultrasound is used to confirm real-time placement out of plane, followed by in-plane visualization to see the catheter in the vessel lumen
When studied in stable emergency department patients when peripheral or external jugular venous access was unsuccessful, the success rate of this procedure was 88% (95% CI 79-94)
The mean time to procedure completion was 4.4 minutes (3.8-4.9)
In 83 access attempts, there were no cases of pneumothorax, infection or arterial puncture
There was a 14% loss of IV patency immediately after insertion
Painful? Don’t forget, these lines were placed without local anesthesia; however, the mean pain score was 3.9 out of 10 (3.4-4.5)
Practical considerations:
So will this technique change your practice? A few things to be aware of:
In obese patients, the target vessel will be inherently more difficult to visualize, as well as the catheter length in this study may not be long enough to ensure patency. The median BMI in the Moayedi et al. (2016) study was 27
Operator skill: the vast majority of lines were placed by clinicians experienced in ultrasound guided line placement. Success and time to placement may be increased as experience decreases
Will more definitive access be required? The catheters placed in this study were largely only used for 24 hours. This would certainly be more than sufficient during the treatment of an ED patient, but usage time increases, infection rates will likely increase
Will this line achieve the infusion rate you need? See this article on infusion rates of various IV catheters
The bottom line: the “easy IJ” is a rapid, effective and safe alternative to establish IV access in stable patients in whom peripheral and external jugular venous attempts have failed.
References
(1) Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. J Emerg Med 2013 Jan;44(1):150-154.
(2) Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med 2016 Dec;51(6):636-642.
