1. External Jugular
Geisinger Life Flight

2. FYI External Jugular vein access is a peripheral IV
Cannulation should not exceed 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

3. Indications 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

4. Equipment Needed for EJ insertion
Gloves
IV start pack
J-loop (optional)
14, 16, 18 gauge angiocath
2x2s
Sterile occlusive dressing
Tape
IV solution and primed IV tubing

5. #18 Angio

6. Additional Supplies

7. Positioning Patient 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

8. Positioning of Patient
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

9. Head down & turned

10. Location of the External Jugular Vein
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

11. Anatomy of the Neck

12. External Jugular

13. Procedure 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

14. Procedure
Cleanse the site with an approved anti-microbial for 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

15. Palpate for the EJ

16. Cleanse the site

17. Tourniqueting

18. Tourniqueting

19. Procedure
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 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

20. Anchor the vein

21. Perform the venipuncture

22. Advance the catheter without the stylet

23. Once the vein is accessed
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

24. Attach the IV tubing or “J loop” to the Angiocatheter

25. Apply the occlusive dressing

26. Secure the IV tubing

27. Monitoring the site
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

28. Complications 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

29. Documentation 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

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

31. Contraindications 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

32. References
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