HWN Suggests

Trick of the Trade: Winging It with External Jugular Cannulation

Imagine yourself caring for a patient that needs urgent vascular access, but several attempts at peripheral intravenous (IV) cannulation have been unsuccessful. You aren’t quite at the point where emergent intraosseous or central venous access is indicated. Maybe those options aren’t even available where you’re working. From across the room, though, you can see a very prominent external jugular (EJ) vein. Sadly, you remember the last EJ line you placed falling out almost immediately.

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Articles of Interest

A Forgotten Vein: The EJ

Once landmark-based attempts have been unsuccessful, before reaching for an ultrasound, consider the oft-neglected external jugular vein. Place the patient in Trendelenburg position and have them rotate their head away from the target vessel. While standing at the head of the bed, use your left thumb to provide traction and your index finger to compress the vein proximally. Cannulate midway between the angle of the jaw and the clavicle. Having the patient perform a Valsalva maneuver can also further distend the vessel.

External Jugular Access

Administration of intravenous medications or fluids where peripherally inserted intravenous catheters (PIVC) or intraosseous catheters (IO) are inappropriate, unsuitable or unavailable.

External Jugular IV Cannulation

External jugular vein cannulation is indicated in a critically ill patient >12 years of age who requires intravenous access for fluid or medication administration and in whom an extremity vein was not attainable.

External jugular vein cannulation – A double-edged sword

Although there are several advantages to securing EJV, it is not without its share of complications. To state a few are, EJV being continuous with the central compartment, its cannulation and removal can lead to air embolism

The Effect of the Valsalva Maneuver on the External Jugular Vein

In conclusion, although the Valsalva maneuver increased the EJV CSA and decreased the EJV depth, it did not greatly improve the EJV’s visibility.

The external jugular vein as the first choice for central venous access in critically ill patients with severe coagulopathy

We conclude that the EJV approach can be used efficiently and safely for central venous catheterization in unstable, critically ill patients with severe coagulopathy.

Trick of the Trade: Bend the IV angiocatheter

Bend the proximal 1/3 portion of the needle slightly about 10-15 degrees. This allows you to approach the EJ vein at a shallow angle without hitting the mandible. Once you get a flashback of blood, feed the catheter as you normally would.

Trick of the Trade: External jugular tourniquet

Wrap your stethoscope around the patient’s neck. This occludes the EJ in a comfortable manner without restricting the trachea. An often obscure EJ plumps up and becomes visible or palpable.

Trick of the Trade: Hum-out the jugular veins

Have the patient hum during IV placement. Humming increases the venous size of the external jugular (EJ), internal jugular (IJ), and common femoral vein (CFV). It is a closed-mouth, forced expiration which increases intrathoracic pressure.