# Going for the EJ



## Shishkabob (Jul 4, 2010)

I had a patient today, left sided neck pain, EXTREMELY diaphoretic, N/V, T-inversion in V2-V5, history of 5 MIs and a triple bypass.

He had NOTHING for veins.  The only ones I could find were tiny ones on his hands that I tried 22's on and couldn't get.  We get to the hospital and the staff attempts several other places.  Finally the doc did an EJ.



My question is when do YOU do an EJ?  In hindsight I could have done one, but I'm still in the area where I think me missing IVs is more of me sucking than the patients veins sucking, and I'd rather not go in to the ER with all my patients having an EJ following a missed AC, just for the hospital to find another suitable vein 




Do you personally save the EJ for crashing patients, or are you a bit more liberal?


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## MrBrown (Jul 4, 2010)

They are generally reserved for people who are crashing and in serious need of fluid or medication.

Having said that the inclusion of adults in our use of intraosseous access should see thier decline.


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## WTEngel (Jul 4, 2010)

If there is a medication that I MUST administer to save life or limb, and there is no other access available, I will go for an EJ. 

If you need access and that is your only option, then it should be defensible, if allowed in your protocols. You better be able to prove that you NEEDED access and you had NO other options, otherwise, it may come under scrutiny...and who needs that headache?

As my favorite medical director always said: treat the treatable, take away the pain, and above all else, do no harm. Follow these three basic tenets, and you will steer clear of trouble 99.9% of the time.

TE


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## akflightmedic (Jul 4, 2010)

Ez-io


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## 82-Alpha599 (Jul 4, 2010)

I love EJs, great veins.  
Only for crashing/about to crash or trauma when you cannot get anything else.  in your situation starting an EJ would only have increased your pts anxiety putting more stress on the heart.  

only did one on an A&Ox4 pt and that's because she told me to go there because that's all she had and is use to it.


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## Epi-do (Jul 4, 2010)

Like everyone else has already said - only if I truly need access for a patient that is crapping out on me.  

So far, I have only every had to start one in the field, and that was a patient that had taken 60 betablockers and chased them with some ativan.  Layining completely flat on her back, her pressure was barely 60/nothing.  I did look everywhere else and there just wasn't anything to be found.  She turned her head to talk to me and there it was...  I told her not to move, let her know what I was doing, and popped it in.  I gave her some glucagon, and by the time we got her to the ER, her pressure was approaching 70 systolic.  Not a great improvement, but it was headed in the right direction.  The ER put her on a glucagon drip, along with some D5W and an epi drip.  When we were leaving, her pressure was around 90.


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## TransportJockey (Jul 4, 2010)

I've done two in the field and both were on GSWs w/ a history of IVDA. Other than that I'll just try and make do wiht something a little less drastic


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## Bulldog Medic Student (Jul 4, 2010)

EZ IO works great.


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## MSDeltaFlt (Jul 4, 2010)

An EJ is a peripheral vein.  Treat is as such.  If your pt needs an IV access, not necessarily crashing, and has no arm veins, tilt the head over.  You'll be fine.


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## Lone Star (Jul 4, 2010)

Since we're talking about IV's here, can someone please answer a question for me?

I was taught that we start peripherally and move medially when starting IV's.  The rationale behind it is that you always go superior to the area that you've just missed the IV in to limit extravasation.

With that in mind, it seems rather apparent that we start IV's in the back of the hand and move 'up the arm' as needed.  (Unless of course, we need a bigger vein for rapid infusion)

That being said, is it just out of pure laziness that I see so many going straight for the A/C?  Furthermore, when heading straight for the A/C, doesn't that start limiting your access points in that extremity right off the bat?


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## MSDeltaFlt (Jul 4, 2010)

Lone Star said:


> Since we're talking about IV's here, can someone please answer a question for me?
> 
> I was taught that we start peripherally and move medially when starting IV's. The rationale behind it is that you always go superior to the area that you've just missed the IV in to limit extravasation.
> 
> ...


 
Usually, yes.  You start where you're told to start for the exact reasons why you mentioned.  That being said, I usually like to start in the forearm.  The forearm does not bend thus occluding the flow, usually has larger veins so you can use larger caths, and the hopsital can draw from below the IV site if need be.  Just my personal preference.


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## Fox800 (Jul 4, 2010)

Linuss said:


> My question is when do YOU do an EJ?  In hindsight I could have done one, but I'm still in the area where I think me missing IVs is more of me sucking than the patients veins sucking, and I'd rather not go in to the ER with all my patients having an EJ following a missed AC, just for the hospital to find another suitable vein
> 
> 
> 
> ...



Somehwere in between "let's start an IV" and "I don't have time to screw around, let's do an IO".


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## jjesusfreak01 (Jul 4, 2010)

Fox800 said:


> Somehwere in between "let's start an IV" and "I don't have time to screw around, let's do an IO".



Screw around??? Thats funny, since you use a drill...


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## redcrossemt (Jul 4, 2010)

I don't know why everyone is talking about EZ-IOs! The EJ is a peripheral IV site. In my protocols and my mind, it's preferred to an IO.


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## ffemt8978 (Jul 4, 2010)

redcrossemt said:


> I don't know why everyone is talking about EZ-IOs! The EJ is a peripheral IV site. In my protocols and my mind, it's preferred to an IO.



And my medical director has made EJ's online medical control only, preferring we use the EZ-IO before calling in and asking permission to do an EJ.

MSDeltaFlt, I agree with you and usually try for the forearm first before I go for an AC.


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## usafmedic45 (Jul 4, 2010)

> In my protocols and my mind, it's preferred to an IO.



So they would rather have a delay than an IO?


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## Melbourne MICA (Jul 4, 2010)

*Anatomy*

I haven't heard anatomy mentioned anywhere when this discussion is held. Know your vein anatomy. 

"Blind" attempts at veins don't have the failure rate you might think because funnily enough veins are usually in around about the same spots in most people. 

Using feel is also underated. One tip is to position your fingers over an area where you should expect to find the vein and tap the skin proximal to the vein. A "pulse" in the vein can be felt to help identify its position.

Cold limbs also make make it hard to find veins. Warm up one hand for example with whatever means are at your disposal - one tip is to put one of your nitrile gloves on the pts hand ( a clean one of course). The hand heats up and sweats making the skin leathery and flushed but do it early on when you take your first look and figure veins are going to be problematic and keep checking other spots in the interim because it takes a little while.

Another is of course to put on two tourniquets (one on each arm of course) or even a third round a lower limb (ankle for example) concurrently. (Don't forget to take the others off once you find a vein).

Under the wrist (anterior) whilst uncomfortable for the pt is almost always a spot for a 22 or 24.

Blind cube fossae attempts are always worth a go. These are big veins in anyone and if you recall your anatomy - the median cubital, basilic and cepahalic veins are there so fish around - uncomfortable for the pt yes so apologise profusely but try. You don't always have to see veins to locate them.

The EJ is a high risk vein and should be reserved for preferably unconscious pts.

As for IO - a reiterate my concern that guys see this as a first line alternative to a perpiheral IV.

There are many less risky admin options for drugs - oral, inhaled even PR so I would certainly recommend trying them first before getting overzealous with EJ and IO's.

Naturally where immediate life threat exists take what you can find. Lastly have a look to begin with - if you can't find anything initially get on with your other jobs and come again later. That flat poorly perfused pt with no BP who had no veins in the house may be a different story once you put their legs up on the bed and load them. Keep looking - pt conditions change - so does the can't find any veins situation. 

MM


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## Fox800 (Jul 4, 2010)

Curious if anyone else is permitted to perform blind sticks for an EJ. We are not, we must be able to visualize the vein prior to our attempt.


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## Melbourne MICA (Jul 5, 2010)

*Caveat*



Fox800 said:


> Curious if anyone else is permitted to perform blind sticks for an EJ. We are not, we must be able to visualize the vein prior to our attempt.



It's good point and worth a clarification. I would suggest to NEVER do a blind attempt on an external jugular. Cube fossaes, hands etc - that's another story.

MM


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## FLEMTP (Jul 5, 2010)

its not often I go for an EJ... but I use them when I need an IV line for fluids or meds... not just to put a saline lock on it.

If they are doing THAT poorly.. I prefer just to place a subclavian central line. Its easier especially if the peripheral circulation is shutting down or collapsing due to volume issues.


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## terrible one (Jul 5, 2010)

MSDeltaFlt said:


> An EJ is a peripheral vein.  Treat is as such.  If your pt needs an IV access, not necessarily crashing, and has no arm veins, tilt the head over.  You'll be fine.



+ 1

Why is everyone so afraid of an EJ? Crashing or dying pts only? Why?
We practiced EJs in class, why is it so high risk? I'm not going to go fishing around for one or just start one to do it, but if I need IV access and the pt has not other available veins i'll be doing an EJ. 
Our county prefers EJs to IOs. and if you do an IO without attempting an EJ it will come up in a QI meeting.


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## Melbourne MICA (Jul 5, 2010)

*Excuses*

It's not so much being afraid of doing one - we've all done them. Rather some of the guys were making the point its sometimes too easy to make excuses for not getting perpiheral access. The other point is of course that risk is far too easily dismissed when we become complacent, frivolous or reckless - or lazy. That part of the neck is filled with structures that won't take too kindly to be stabbed by a 16g stillette. And I guess we can't forget that its a little awkward to get at compared to a hand or arm adding to risk.

It's a great big long straight vein which in most people stands out pretty well. But I don't think you can ever be too careful when evaluating risk. Its just about options and balancing risk against value  -a bit like drugs really.

For FLEMTP, "If they are doing THAT poorly.. I prefer just to place a subclavian central line. Its easier especially if the peripheral circulation is shutting down or collapsing due to volume issues".

Are you guys allowed and is it practical and safe to do a central line in the field? Like on the roadside on a trauma victim or on the floor of some housing commission apartment?

After just having talked about risk - a mandatory aseptic high risk procedure with suturing, closed fields etc. And "easier" than a EJ?

Any more info or are you doing a procedure with the same name as the one I've seen done and occasionally helped with in the ED?

MM


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## FLEMTP (Jul 5, 2010)

Melbourne MICA said:


> It's not so much being afraid of doing one - we've all done them. Rather some of the guys were making the point its sometimes too easy to make excuses for not getting perpiheral access. The other point is of course that risk is far too easily dismissed when we become complacent, frivolous or reckless - or lazy. That part of the neck is filled with structures that won't take too kindly to be stabbed by a 16g stillette. And I guess we can't forget that its a little awkward to get at compared to a hand or arm adding to risk.
> 
> It's a great big long straight vein which in most people stands out pretty well. But I don't think you can ever be too careful when evaluating risk. Its just about options and balancing risk against value  -a bit like drugs really.
> 
> ...



Subclavian central lines are authorized in our agency and do not require us contacting medical control. We have a 3in 16 ga angiocath that we place them with. we are expected to do a betadine scrub prior to placement. It is actually quite easy to place when you follow the landmarks. In fact a subclavian central line placement has the lowest risk when it comes to  placement complications vs other types of central venous lines.

i am attaching a copy of the procedure from our guidelines


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## Melbourne MICA (Jul 5, 2010)

FLEMTP said:


> Subclavian central lines are authorized in our agency and do not require us contacting medical control. We have a 3in 16 ga angiocath that we place them with. we are expected to do a betadine scrub prior to placement. It is actually quite easy to place when you follow the landmarks. In fact a subclavian central line placement has the lowest risk when it comes to  placement complications vs other types of central venous lines.
> 
> i am attaching a copy of the procedure from our guidelines



How many central lines would you average and under what circumstances are they practical? ( I haven't been able to access your guidelines procedure material as yet).

My understanding of central lines is they require a closed sterile field, with mask, gloves, goggles, a betadine clean and need surgical incision, suturing etc. Doesn't sound like an in-field appropriate procedure to me but since you apparently do them some elaboration about your experiences would be appreciated especially in light of the EJ discussion.

Cheers

MM


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## Akulahawk (Jul 6, 2010)

FLEMTP: That guideline is for IJ placement, not subclavian...


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## Flight-LP (Jul 6, 2010)

I'm glad i'm not the only one who noticed that. I thought my eyes were deceiving me before I had my morning coffee!

For what it's worth, I personally feel that central access has no place in emergent pre-hospital services. With the common utilization of rapid I/O access, there really is no need. Add to that the ease of insertion with the EJ and you have very few justifications for starting a central line in the field pre-hospital.


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## sdadam (Jul 6, 2010)

Wow, I do EJs pretty regularly!

In the patient described by the original poster I would have no qualms about going for an EJ.

The consensus seems to be to wait until the patient is crashing, or is in need of medication immediately, but by then IMO you already missed the opportunity to prevent this if you don't have IV access.

I have plenty of times started an EJ just to have access because I gave decent probability to the patient declining, just because they didn't doesn't mean my EJ was uncalled for.


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## Melbourne MICA (Jul 7, 2010)

*IV anxieties*



sdadam said:


> Wow, I do EJs pretty regularly!
> 
> In the patient described by the original poster I would have no qualms about going for an EJ.
> 
> ...



No I don't think that's the consensus. If anything the consensus is EJ is a good option, has higher risk than peripheral IV's so should be used with care but EMS types often go for seemingly "easier" options befor really exploring safer IV sites. It's certainly not the case of waiting for anything especially for a pt to crash. The  dynamics of each pt situation dictate what approach you will take. We just need to be sure as with anything we do to a pt that our decisions are measured and weigh up the balance of risk versus benefit.

There are practical, clinical and other factors that influence this choice to be sure. What happens with the trauma pt if your first thought is an EJ but you have to collar the pt? What happens to your choice of IO in the first instance when the trauma pt has limb fractures, is covered in filth and grime (pretty common) and you need to use the arms for your NIBP cuff, for pulse ox etc?

Just some examples. It's really a case of surface area and precentages. Lots of places where a safer IV site can be established which doesn't interfer with your other tasks.

MM


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## sdadam (Jul 7, 2010)

Melbourne MICA said:


> No I don't think that's the consensus. If anything the consensus is EJ is a good option, has higher risk than peripheral IV's so should be used with care but EMS types often go for seemingly "easier" options befor really exploring safer IV sites. It's certainly not the case of waiting for anything especially for a pt to crash. The  dynamics of each pt situation dictate what approach you will take. We just need to be sure as with anything we do to a pt that our decisions are measured and weigh up the balance of risk versus benefit.
> 
> There are practical, clinical and other factors that influence this choice to be sure. What happens with the trauma pt if your first thought is an EJ but you have to collar the pt? What happens to your choice of IO in the first instance when the trauma pt has limb fractures, is covered in filth and grime (pretty common) and you need to use the arms for your NIBP cuff, for pulse ox etc?
> 
> ...



I actually feel like the consensus is as I stated, take a look:



> They are generally reserved for people who are crashing and in serious need of fluid or medication.





> If there is a medication that I MUST administer to save life or limb, and there is no other access available, I will go for an EJ.





> Ez-io





> Only for crashing/about to crash or trauma when you cannot get anything else.



I tend to agree with the minority of replies:



> An EJ is a peripheral vein. Treat is as such. If your pt needs an IV access, not necessarily crashing, and has no arm veins, tilt the head over. You'll be fine.





> I don't know why everyone is talking about EZ-IOs! The EJ is a peripheral IV site. In my protocols and my mind, it's preferred to an IO.



Just sayin'


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## Melbourne MICA (Jul 7, 2010)

*Touche"*



sdadam said:


> I actually feel like the consensus is as I stated, take a look:
> 
> 
> 
> ...



OK you win and I won't be argumentative but I'll just say my point is that you can get other IV's but guys often don't try hard enough before going for an EJ. Besides, EJ's can be missed as well as can IO's, perhaps less so with devices like EZIO and perhaps thats the point because technically you've ruled out any lines distal to the Ej when you do miss it,  hence guys leaving it for the crashing pt. My points about the practicalities still stand.

Ok.....so I was a bit argumentative. Any port in a storm as they say.

Cheers
MM


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## DrParasite (Jul 8, 2010)

I once had a patient who was seizing.  ALS spent 15+ minutes on scene, attempting to get an IV.  once in a the hand, twice in the arm, twice in the other arm, once in the foot, and finally they attempted an EJ.  All were unsuccessful.  

after 20 minutes, we finally carried the still seizing patient to the truck, where they finally went for an IO.

While I can understand why you would want a peripheral vein, if you are fishing for a vein in the neck, why not just go for the IO if vascular assess is so important?


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## reaper (Jul 8, 2010)

Why did they not administer IM?


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## usalsfyre (Jul 8, 2010)

DrParasite said:


> I once had a patient who was seizing.  ALS spent 15+ minutes on scene, attempting to get an IV.  once in a the hand, twice in the arm, twice in the other arm, once in the foot, and finally they attempted an EJ.  All were unsuccessful.
> 
> after 20 minutes, we finally carried the still seizing patient to the truck, where they finally went for an IO.
> 
> While I can understand why you would want a peripheral vein, if you are fishing for a vein in the neck, why not just go for the IO if vascular assess is so important?



IM or IN?

 An EJ is less invasive than an IO. It's still a peripheral line, albeit one with a higher risk profile than other areas. Agree with what was said before, for me and EJ falls between "let's start a line" and IO


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## Ridryder911 (Jul 9, 2010)

I did not read all of the responses do forgive me, if I repeat a post. As one that has established literally hundreds on EJ IV acess I too can attest the ease of them and how nice they are..... *BUT *

here's the problem.. more and more research is demonstrating that there is a large amount of air that is being introduced when cannulating and attaching IV tubing. Even if one is "occluding" the vein; significant amount of air is entering the vascular system. 

The new talk is... if have a patient that goes into a PEA condition after establishing an EJ.. chances are you introduced a P.E. ... 

I look for this procedure to fall to the waste side with other more safer and easier techniques. No, I/O do not have that high of incidence due to the nature of bloodflow but one still has to be cautious when flushing IV line alike all other IV cannulations. 

R/r 911


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## bstone (Jul 9, 2010)

Perhaps time to use EZ-IO.


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## Lone Star (Jul 10, 2010)

Ridryder911 said:


> No, I/O do not have that high of incidence due to the nature of bloodflow but one still has to be cautious when flushing IV line alike all other IV cannulations.
> 
> R/r 911





bstone said:


> Perhaps time to use EZ-IO.



In the situation that Rid was describing, I seriously doubt that things will be different because you used an EZ-IO as opposed to a standard T-handled I/O cath.

What Rid appears to be referring to is introducing an air embolism due to not properly flushing the IV line before connecting it to the catheter.


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