External Jugular Vein Cannulation

June 2000, MERGINET - Under the best of circumstances, obtaining IV access in the prehospital setting can be challenging. A less than optimum environment combined with a critically ill or injured patient can make this task very difficult. The patient in shock or cardiac arrest can be particularly troublesome. Having a variety of options for IV access is optimal.

When patients are in hypovolemic type states and/or circulatory collapse it may be difficult or impossible to establish access from a peripheral vein. Studies have demonstrated a significant delay in the arrival of a drug at the heart when peripheral IV sites are used for injection, even during effective chest compression. Drugs administered via a peripheral vein reach a lower peak concentration and take longer to reach the central circulation than do drugs given via a central vein. 1,2 Thus, the perfect route of access would be a peripheral vein, large in size, easy to cannulate, and offering quick access to central circulation. The external jugular vein has all of these attributes.

The external jugular vein lies superficially along the lateral aspect of the neck. It extends from the angle of the mandible and runs downward until it pierces the deep fascia of the neck just above the middle of the clavicle, and ends in the subclavian vein.

The external jugular vein is a peripheral vein and therefore is within most providers' protocol/practice area. It is a large vein and under many circumstances surprisingly easy to cannulate. Using the external jugular vein for access does have its drawbacks. It is not readily accessible if personnel are trying simultaneously to control the patient's airway. It is a very superficial vein and can be mobile and tend to "roll." The external jugular vein can also be positional with slight movement of the head effecting the flow of the fluid.

The complications of external jugular vein cannulation are the same as for any IV start or infusion, and may include hematoma at the insertion site, cellulitis, infection, phlebitis, infiltration of IV fluid at the site, and embolism of air, blood, or catheter fragment. 2,3 There is also a remote danger of puncturing the thoracic cavity and giving the patient a pneumothorax. The risk of air embolism is also present; thus a syringe/angiocath combo should be used to perform the procedure.

Trauma patients with potential cervical spine injuries should be approached with caution. At no time should the patient's neck be rotated or extended to enhance access. If you are unable to obtain access with the patient's head in a neutral/midline position, other IV access sites should be used.

Technique
With the patient in the supine, head down position, rotate the head to the opposite side. Applying digital pressure to the vein distally (just above the clavicle) will often assist in distending the vein. Insert the needle in the middle of the vein. The vein is very superficial! Aspirate after puncturing the skin and immediately upon seeing a flashback, thread the catheter. Stop if you meet resistance. This is essentially the same technique that is used with other peripheral veins except the provider must keep in mind the special anatomical considerations. Remember, you are cannulating a large vein very close to the central circulation, thus the higher risk of air embolism. The vein is located in an area with several large vascular and nervous system structures, so be careful.

Once the external jugular vein has been successfully cannulated, secure the catheter well. A transparent dressing is optimal and will allow you to reassess for infiltration. You can loop the IV tubing around the patient's ear for added protection against accidental dislodgment, but it is hard to tape the tubing well, especially if the patient has long hair. Another way to tape the tubing is to place it across the patient's forehead. On most IV sets this will place the injection port at the patient's forehead, allowing easy access to push drugs and a secure area to tape the tubing. It is not very aesthetically pleasing but will get the job done. If the patient is able to keep his/her head in a neutral/midline position, so much the better. If the patient is unconscious you may tape his/her head in this position or use head blocks on either side. Keeping the head in a neutral position seems to optimize IV flow. After cannulating the external jugular vein the provider can station himself at the patient's head and be able to ventilate the patient and give drugs from this position. In cramped quarters, such as an ambulance or helicopter, this is very convenient. This can potentially free up another rescuer to perform other resuscitative measures.

The external jugular vein is an excellent site for access to the central venous circulation. Much like the intraosseous route, the external jugular vein probably should not be used as a primary insertion site, but rescuers should think about external jugular vein cannulation sooner rather than later, especially in the cardiac arrest or acutely ill patient.

Conclusion
When the need arises for fast and easy vascular access in a critically ill/injured patient, rescuers should think of the external jugular vein. This guarantees rapid access to central circulation and allows the rescuer to remain at the patient's head. It takes no special equipment and with knowledge of the specific anatomy is not too difficult a skill to master.

References

•  Kuhn G.J., White B.C., Swetnam R.E., et al. Peripheral vs central circulation times during CPR: a pilot study. Annals of Emergency Medicine , 1981 10: 417-419

•  Hedges J.R., Barsan W.B., Doan L.A., et al. Central versus peripheral IV routes in CP resuscitation. American Journal of Emergency Medicine , 1984 2:385-390

•  Lee, Genell. Flight Nursing: Principles and Practice , Mosby Books, 1992

Kevin High, RN, MPH, EMT, is a flight nurse with Vanderbilt LifeFlight in Nashville , TN. He has 14 years of prehospital experience and has had other articles in Air Med , Journal of Emergency Nursing , Air Medical Journal , and Emergency Medicine . He actively lectures on local, state, and occasionally national levels. He lives in rural Middle Tennessee and is happily married to a local hospital executive.