Intravenous (IV) access is a basic and invaluable skill for emergency physicians. For patients requiring rapid fluid resuscitation, airway management, or medication administration, the placement of one or more IV lines is absolutely essential. Most patients do well with a simple, landmark-based, blind placement of a superficial peripheral IV. However, we often encounter situations where this may be difficult or impossible to achieve, and so we all should have a repertoire of other sites and techniques to employ.
Ultrasound-Guided Deep Peripheral IVs
Ultrasound-guided IV placement has been shown to be safe, quick, and patient-friendly in adults and children [1, 2]. In at least 10% of patients, we encounter in the ED, blind insertion of a peripheral IV may be complicated by obesity, edema, IV drug use, surgical scars, dialysis, burns, etc. Obtaining peripheral IV access rapidly can avoid the time and risk associated with central venous catheterization or the discomfort of intraosseous access.
Deep veins of the upper arm are generally larger and are the best targets, especially the basilic and cephalic veins.
Ideal in these situations: Peripheral IV candidates complicated by obesity, IV drug use, or inability to lie flat for procedures
Not ideal in these situations: Central access needed, cardiac arrest
Optimal positioning: Ideally, position patient with shoulder slightly abducted, elbow completely extended, forearm completely supinated. The ultrasound machine should be placed next to the patient’s head or on the opposite side of the bed, so that you turn your neck as little as possible.
Method:
Use a long (1.8 or 2.5 inch) catheter because it typically needs to traverse through more tissue to a deep vein.
Clean the ultrasound transducer should be cleaned and apply sterile lubricant.
Apply a tourniquet proximal to the site.
Use universal precautions.
Clean the skin just distal to the probe with an antiseptic swab.
Use the linear ultrasound transducer and adjust the position/depth so that the vessel is in the center of the image.Veins will be thin-walled and easily compressible, compared with arteries that will be thick-walled and non-compressible.
Insert the needle at a 30-45 degree angle, just distal to the ultrasound probe.
Slowly sweep the probe proximally as the needle tip moves proximally.
Once a flash is seen in the IV chamber, the rest of the procedure proceeds similar to the blind technique.
Drop the angle of the needle about 15 degrees and advance it another 1-2 mm to ensure that both the tip of the catheter and the needle are in the vein.
Hold the needle in place as the catheter is completely advanced.
Complications: Paresthesias, brachial artery puncture, hematoma formation, IV decannulation
Pearls:
The best target will be the vein that is the largest and most superficial.
For deep veins, angle your catheter at a steeper angle than you would for a superficial vein (35-45 degrees).
You can use the ultrasound to confirm catheter placement afterwards by visualizing tiny bubbles within the vessel during saline flush. Anechoic fluid in the soft tissue suggests extraluminal placement.
Resources:
Mike and Matt’s Ultrasound Podcast on Ultrasound Guided Peripheral IVs
SAEM Narrated Lecture Series on Ultrasound Guided Peripheral IVs
ALiEM’s Pediatric Central Venous Catheters for Deep Peripheral IVs
External Jugular Vein (EJ)
The EJ vein is a great site for rapid IV access. It can often be accessed without ultrasound guidance and is a large vein that can often be used for medication/fluid administration and phlebotomy. Vasoactive medications and radiographic contrast should not be administered due to potential complications such as extravasation and airway compromise. The EJ vein courses over the sternocleidomastoid (SCM) before joining the subclavian vein under the clavicular head of the SCM.
Ideal in these situations: Ultrasound not readily available, EJ vein easily seen on exam
Not ideal in these situations: Unable to visualize landmarks on neck, patient unable to tolerate laying flat
Optimal positioning: Position the patient in Trendelenburg about 10-15 degrees. Turn head slightly away from side of EJ cannulation.
Method:
With the patient positioned properly, cleanse the site and use a finger to provide slight traction next to the vein to anchor it.
Approach the vein at a 5-10 degrees angle, about midway between the angle of the jaw and the clavicle.
After a blood flash return in the IV catheter, advance the catheter until the hub is secure against the skin.
Complications: Hematoma, laceration of the deeper internal jugular vein, air embolism, infection, airway compromise
Pearls:
Reduce vein rolling by puncturing the vein from the side or selecting a bifurcation site.
Secure the IV around the ear to prevent dislodgment.
Trick of the trade: You can use your stethoscope as a “tourniquet” for EJ IV placement
Trick of the trade: You can bend the angle of the angiocatheter if the jaw is in the way
Trick of the trade: Have the patient hum if they cannot tolerate Trendelenberg to increase venous distension
Resources:
Start at the 1-minute mark for the actual procedure.
Intraosseus (IO) Line
An intraosseus line is used for emergent vascular access when one is unable to obtain peripheral venous access. It allows you to draw almost any lab, including blood cultures and lactate, as well as administer large volumes of fluid, blood, inotropes, and vasopressors. While historically used in pediatric cardiac arrest, IO access is also used in adult resuscitation for rapid vascular access. The most common site for IO access in the anteromedial tibia, 1-2 cm distal to the tibial tuberosity. Alternative sites include the humeral head and the distal femur in the anterior midline above the external epicondyles, 1-3 cm proximal to the femoral plateau.
Ideal in these situations: Cardiac arrest or profound cardiogenic shock, when peripheral or central access have failed or are difficult
Not ideal in these situations: Previous IO attempts in the same bone, osteogenesis imperfecta, osteoporosis, proximal fractures, overlying infection or skin damage
Method: This assumes use of a powered device, such as the EZ-IO.
Sterilize the insertion site with povidone-iodine, chlorhexidine, or alcohol.
Use your nondominant hand to stabilize the arm or leg.
Insert the IO needle perpendicular to the bone. The resistance suddenly decreases once the marrow cavity is entered.
Remove the trocar.
Use a 5- to 10-mL syringe to aspirate blood for confirmation.
Slowly instill lidocaine into the intraosseous space to anesthetize the visceral pain fibers.
Observe the area for signs of extravasation.
Secure the needle and immobilize the extremity.
Pearls:
For humeral IO insertion, be sure the patient’s shoulder is internally rotated (patient’s hand on his/her abdomen).
Monitor the extremity continuously for compartment syndrome.
IOs should be removed within 24 hours.
For removal, connect a Luer lock syringe to the hub of the catheter, and twist clockwise while pulling the needle straight out. Do not rock back and forth which could cause bone cracks.
Infusion is still going to be painful despite lidocaine.
EZ-IO drills are not to be used for the sternum like they do in the military. They use a different apparatus.
Complications: Extravasation
Resources:
ALiEM post on IO access
MDAware blog post on IO pearls
Central Venous Access
Central venous access is indicated for infusions that require larger, less fragile veins, such as vasopressors, hyperosmolar solutions, and hyperalimentation (Note: vasopressors can be infused peripherally in certain circumstances per EMCrit.) Central access could also be considered when peripheral IV access is very difficult, such as with extensive burns to the body, or if multiple medications need to be infused, or blood draws need to happen frequently. A 2012 Critical Care Medicine systematic review suggests that there is no difference in catheter-related bloodstream infections between the three typical sites: internal jugular, subclavian, and femoral veins. The best site to place a central line can depend on several factors detailed below. Ultimately, line selection is a complex clinical judgment rather than a ‘one size fits all’ strategy. It is driven by setting (level of hemodynamic instability, risks for abrupt crash), patient factors (anxiety, cooperativeness, sedation levels or safety for sedation, airway sustainability/adequacy/patency), operator experience and flexibility, and probable need for multiple drug infusions and therapies.
Pearls:
Trick of the Trade: Use the plastic guidewire sheath as a quick pressure transducer to differentiate arterial from venous cannulation.
MDaware’s Tricks of the Trade on central lines
Life In The Fast Lane discussion on central line placement
Internal Jugular (IJ) Vein
The IJ vein is often the ideal site to place a central line. An IJ central line will allow placement of a pulmonary artery catheter or a transvenous pacing wire, as well as for measurement of CVP. The IJ vein typically lies anterolaterally to the carotid artery at the apex of the triangle formed by the clavicle and the two heads of the sternocleidomastoid muscle.
Ideal in these situations: Most central venous access needs
Not ideal in these situations: Patients who cannot lay flat or have respiratory distress, distorted anatomy or trauma at site, suspected cervical spine fracture
Optimal positioning: Place patient in 15 degree Trendelenburg position and rotate patient’s head opposite the site of cannulation.
Method: The standard basic technique on the placement of a central line will not be reviewed here. Please consult your preferred textbook, or watch the videos below to review the procedure.
Pearls:
The left IJ has a more tortuous route than the right IJ, which may make threading the guidewire more difficult. In addition, the dome of the left lung is higher than the right lung which may theoretically increase the risk of pneumothorax.
Trick of the Trade: Consider using the angiocatheter through which to thread the guidewire to place an IJ, to reduce introducer needle dislodgement
Trick of the Trade: Consider using the long axis view of the linear ultrasound transducer to place and/or confirm the line placement
Complications: Airway compromise from hematoma, pneumothorax, carotid artery puncture, thrombosis, infection
Resources:
Femoral Vein
The femoral vein is a useful site for code/crash situations, where the neck is inaccessible due to active airway management and/or the chest is occupied with ongoing CPR. It it often the easiest site to perform blind central vein cannulation based on landmarks alone, and thus quickest if very rapid central access must be achieved, e.g. in patients in extremis. It is also the site to use if patients cannot lay flat for a subclavian or IJ central line. The femoral vein is classically located medial to the femoral artery, best remembered by the mnemonic NAVEL (from lateral to medial- Nerve, Artery, Vein, Empty space, Lymphatics).
Ideal in these situations: Patients in extremis, code situations, coagulopathic patients, patients who cannot lay flat
Not ideal in these situations: Distorted anatomy or trauma to region, suspected proximal vascular injury (e.g. the IVC)
Optimal positioning: Patient can be sitting about 45 degrees to supine. Externally rotate leg and bend the knee to expose the groin.
Method: Basic technique on the placement of a central line will not be reviewed here. Please consult your preferred textbook, or watch the videos below to review the procedure.
Pearls:
During chest compressions, pulses may be felt in either the artery or vein. Some would argue that it is safer to always choose intraosseus access in cardiac arrest.
If you inadvertently start too inferiorly, your needle may be cannulating the greater saphenous vein, in which it is difficult to introduce the guidewire due to its valves and smaller diameter.
Complications: Retroperitoneal hematoma, thrombosis, infection
Resources:
Placing a femoral central line in a pulseless patient:
NEJM video on femoral central line placement
Subclavian Vein
The subclavian vein is another common site, especially when an ultrasound is not available. The subclavian vein is classically located just over the 1st rib. It lies immediately posterior to the medial 1/3 of the clavicle. It is separated from the deeper subclavian artery by the anterior scalene muscle, and is 1-2 cm in diameter.
Ideal in these situations: For any central venous access needs, ultrasound not readily available
Not ideal in these situations: Coagulopathic patients, distorted anatomy or trauma, pneumothorax on opposite site of cannulation, fracture of the clavicle or proximal ribs
Optimal positioning: Place the patient in Trendelenburg position. The vein is kept patent by surrounding costoclavicular ligaments but Trendelenburg position will help prevent air embolism. Place a small towel between the scapulae to reduce deltoid muscle bulge. Abduct arm slightly.
Method: Basic technique on the placement of a central line will not be reviewed here. Please consult your preferred textbook, or watch the videos below to review the procedure.
Pearls:
Most patients with a malpositioned catheter were into the IJ. Apply external pressure over the base of the IJ vein using a sterile finger during guidewire insertion to prevent the guidewire from going into the IJ. [Ambesh et al 2002]
Patients with ear pain or a tickling throat sensation during guidewire insertion typically means that the guidewire is in the IJ. [Ambesh et al 2002]
Avoid placing a subclavian line opposite to a known or suspected pneumothorax, due to the risk of creating bilateral pneumothoraces.
Try using ultrasound to guide your placement if anatomy is difficult or with patients who have high risk of pneumothorax.
Complications: Pneumothorax, thrombosis, infection
Resources:
References
Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 2005 Nov;46(5):456-61. PMID 16271677
Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999 Dec;34(6):711-4. PMID 10577399
Shah, Kaushal, and Chilembwe Mason, eds. Essential emergency procedures. Lippincott Williams & Wilkins, 2007.
Additional Reading: Lin, M. (2012). Difficult Vascular Access: Alternative Approaches & Troubleshooting Tips [Powerpoint slides]. Retrieved from UCSF CME Department.
Expert Peer Review
January 16, 2014
Emergency medicine professionals pride themselves on a procedural skillset that is essential to the initial care of acutely ill and injured patients. This includes rapid and effective circulatory access, which facilitates both diagnostic and therapeutic interventions.
The hallmark of ED patients is their undifferentiated nature and acute presentation. Availability of effective routes of vascular access cannot be taken for granted by the emergency specialist. Paramedics and ED nurses have tremendous procedural skill under trying conditions, but occasionally patients present challenges to vascular access. Stable patients also deteriorate, and their needs evolve dynamically.
As nicely summarized by Dr. Lee in this excellent overview, several alternatives to the tried-and-true peripheral IV (PIV) are available to the skilled emergency physician.
Ultrasound-guided PIV (US-PIV) placement is a useful skill, yielding large-bore venous access without the potential complications of a central venous catheter. The use of a long angiocatheter is essential, as tissue rebound and patient movement can easily displace the catheter, rendering it useless and potentially producing hematoma or deep extravasation of infusate.
Although best practices for aseptic technique in US-PIV placement have not yet been established and the full sterile probe cover is not routinely used, I would request one if I were the patient. Alternatively a large Tegaderm transparent dressing can be used to cover the probe directly, limiting some of the risk of insertion site contamination. Either way, use of sterile ultrasound gel (or the water soluble lubricant available for guaiac testing in every ED) is likely far better than the gel kept with the ultrasound machine. US-PIV placement is resource intensive procedure for the emergency physician and can alternatively be used by carefully trained ED nurses.
EJ vein cannulation is an essential tool for emergency physicians, nurses, and paramedics. Patients with poor venous access who can lie flat are excellent candidates for this procedure. Attention should still be paid to aseptic technique and prevention of air embolism. The tips and pearls listed in Dr. Lee’s summary are very useful.
In extremely acute circumstances, there is probably no better option than intraosseous access, which can be obtained in seconds, allows for administration of any resuscitation fluid or medication, as well as collection of all laboratory studies relevant to resuscitation. In this reviewer’s opinion there is virtually never an indication for central venous access in cardiac arrest, except for the eventual placement of a transvenous pacer wire (which should happen after IO access for medication administration).
Following IO placement (after marrow collection for lab analysis) a rapid 10-20 mL flush is needed in order to maximize the subsequent infusion rate. This will be painful in awake patients. Instilling lidocaine first can somewhat blunt this activation of visceral pain fibers. When no longer needed, the intraosseous needle can be easily removed by screwing a 10 mL syringe onto the hub and then continuing to turn in a clockwise direction, effectively “unscrewing” the needle.
Regarding central venous access, although recent review data suggest minimal to no difference in infection rates between sites, this depends on the use of equivalent sterile technique at each site. This is by definition almost never the case when the groin is selected for “crash” central venous cannulation in the ED. The message from the literature is that the site is likely less important than the conditions and technique. The physician considering placing a “crash” femoral or subclavian line under less-than-sterile conditions is usually better served by reaching for the IO kit.
Regarding jugular and subclavian cannulation, Trendelenburg positioning is important both to maximize target size and minimize the risk of air embolism. Patients often feel overheated, claustrophobic, and dyspneic under drapes. This feeling can be ameliorated somewhat by providing sufficient airflow, for example by tenting the drape slightly and/or directing medical air or oxygen toward the patient’s face via oxygen tubing.
While Dr. Lee correctly identifies the classic locations of the central veins, these are well known to vary greatly. For this reason and others, US guidance for these procedures is the approach of choice. That said, it is still important for EM physicians to learn the landmarks, since ED resources vary. I suggest to all my trainees that they first identify the landmark-based site, and then place the US probe at their proposed site of puncture. The resulting image is usually quite informative.
Intermediate and advanced US users may find it useful to use both transverse and longitudinal views for completed access scenarios. As with any US-guided access procedure, it is essential to find and follow the needle tip toward the target.
US can also be used to assist in the placement of subclavian central venous catheters, although they arguably enter more distally, into the axillary vein, which may increase the risk of thrombosis.
Regarding the actual jugular puncture, in my opinion the angiocatheter technique is the ideal option, as it reduces the time that a large sharp object is in the neck near vital structures, particularly while the operator’s attention is on the tray, not necessarily controlling hand movement.
John Litell, DO; Attending Physician, Emergency and Critical Care Medicine, Beth Israel Deaconess Medical Center; Instructor of Medicine, Harvard Medical School
Author information
Terrance Lee, MD
Emergency Medicine Resident
Beth Israel Deaconess Medical Center
Harvard-Affiliated Emergency Medicine Residency
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