     External Jugular vein access is a peripheral IV Cannulation should not exceed 24-48 hours Only 1 attempt on each side of the neck is permitted due to possible airway compromise from infiltration or hematoma formation at the site if the vessel is missed DO NOT use a pressure infuser on an EJ site Irritant solutions (pH<5. pH> or osmolarity >600 mOsm/L, chemotherapeutic agents & vasopressors) are more safely infused into a central vein

     IV fluid administration IV medication administration IV blood or blood product administration IV nutritional support NOTE: Many institutions will not allow administration of a high pressure IV contrast agent into an EJ

        Gloves IV start pack J-loop (optional) 14, 16, 18 gauge angiocath 2x2s Sterile occlusive dressing Tape IV solution and primed IV tubing

     Explain the procedure to the patient &/or family Make sure the room/ambulance/helicopter is adequately lit and warm to assist with vasodilatation Raise the litter HOB is to be put in the Trendelenburg position Instruct the patient to turn his/her head to the opposite shoulder (if c-spine is cleared). Look at both sides of the neck to find the largest external jugular vein

  Place the patient in the supine, head down position with his/her head turned to the opposite side of where initiation is intended This position will help distend the vessel and may prevent an air embolism

 The EJ vein runs downward & backward obliquely (at an angle) behind the angle of the mandible & across the sternomastoid muscle. The EJ then courses deeply into the neck above the midclavicular area and enters the subclavian vein

      Wash your hands Don non-sterile gloves & eye protection If the patient’s skin is visibly dirty, wash with soap & water first Ask the patient to bear down (if awake & able to do so)-this helps to assist with vasodilatation

Note:

Make the puncture on expiration because the EJ tends to collapse on inspiration especially in volume depleted patients

Note:

A warm towel &/or hot pack can be utilized to help distend the vein

   Cleanse the site with an approved anti microbial for 30-60 seconds and allow area to air dry up to 1 minute Once the skin is cleansed, do not touch or re-palpate it Lightly place a finger of your non dominate hand just above the clavicle to produce a tourniqueting effect

       Use the thumb of that same hand to pull traction above the puncture site Anchor the vein and align the cannula with the vein The bevel of the needle should be pointing toward the clavicle. Insert the angio at a 10-30 degree with the bevel up Perform the venipuncture between the angle of the jaw & the clavicle. The site should be as proximal as far above the clavicle to avoid accidental lung puncture Cannulate the vein in a shallow superficial manner When blood is returned, advance the catheter off the needle until the hub is securely against the skin Remove the IV catheter needle & discard

       If drawing bloods due so prior to attaching transparent dressing Attach the IV tubing Apply the transparent dressing Secure the tubing with additional tape (may loop the tubing up around the ear) Label the dressing with “EJ”, date & time of insertion, size of catheter & your initials Avoid circumferential dressing or taping Raise HOB and lower the litter

   Frequently evaluate the EJ site for signs of infiltration (monitor per hospital policy) Discontinue fluid/medications immediately if signs of infiltration are present Extravasations of fluids &/or vasoactive medications into the neck is a serious complication thus diligent monitoring of the site & documentation of patency is required

          Pulmonary Embolism Hematoma (patients receiving anticoagulation therapy are at increased risk for h Hematomas at the insertion site Accidental arterial puncture Catheter shear (which may place the patient at risk for embolus formation Air embolism Bleeding Infiltration/Extravasation Infection Phlebitis

       Date Time Site of insertion Catheter size Patient response to procedure Complications encountered such as hematoma, signs of PE or air embolism, signs of infiltration &/or extravasation Remedies for the complications

 Educate the patient/family regarding excessive head movement & to report any pain, shortness of breath, bleeding, burning or dampness at the insertion site immediately

          Cervical spinal injury Penetrating injury to the neck Significant blunt trauma to the neck Soft tissue injury to the neck VP shunt on the side of intended insertion Neck mass Circumferential burns of the neck Infection at or near intended insertion site Agitated patient (excess moving of head) Clinical &/or physical limitations that would not allow proper securing of the EJ access such as a large neck, no neck, diaphoresis etc

  Campbell, J. (2012). International Trauma Life Support for Emergency Care Providers. Pearson Education Inc.

Holleran, R. (2010). ASTNA Patient Transport Principles & Practice. Mosby. St. Louis, Missouri