Going for the EJ

[terrible one]

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.

 

[Melbourne MICA]

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

 

[FLEMTP]

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

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

 

[Melbourne MICA]

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

 

[Akulahawk]

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

 

[Flight-LP]

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.

 

[sdadam]

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.

 

[Melbourne MICA]

IV anxieties

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.

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

 

[sdadam]

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

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'

 

[Melbourne MICA]

Touche"

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









I tend to agree with the minority of replies:





Just sayin'

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

 

[DrParasite]

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?

 

[reaper]

Why did they not administer IM?

 

[usalsfyre]

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

 

[Ridryder911]

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

 

[bstone]

Perhaps time to use EZ-IO.

 

[Lone Star]

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

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.