Going for the EJ

Shishkabob

Shishkabob

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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 :P




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

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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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.
 
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 :P




Do you personally save the EJ for crashing patients, or are you a bit more liberal?
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Somehwere in between "let's start an IV" and "I don't have time to screw around, let's do an IO".
 
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.
 
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.
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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.
 
In my protocols and my mind, it's preferred to an IO.
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So they would rather have a delay than an IO?
 
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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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.
 
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.
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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
 
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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