8.1

Vascular Access

Chapter 8

Vascular Access

Introduction

Vascular access is a critical early step in the management of

trauma. Peripheral access should be attempted first; if

unsuccessful, additional percutaneous central access locations

include the subclavian vein, the internal and external jugular

veins, and the common femoral veins. Cutdowns for the

saphenous vein at ankle or femoral sites are alternative options.

 Basic Equipment.

ο Tourniquet.

ο 1%–2% Lidocaine.

ο Sterile prep solution, drape, gloves, and 4 x 4 gauze pads.

ο 3mL syringe with 25-gauge needle.

ο Scalpel, hemostat, 11 blade scalpel and fine scissors.

ο Vein introducer or “vein pick”.

ο IV catheter; IV tubing (modified with distal connector cut

off), and 8 F NG tube are field expedients.

ο 3-0 or 4-0 silk ties to secure catheter in vein.

ο 2-0 or 3-0 suture to secure catheter to skin.

ο Central catheter kit (for central lines) or intraosseous device

for intraosseous insertion.

Subclavian Vein Access or Internal Jugular Venipuncture

 Place the patient supine in Trendelenburg (15° head down).

 Prep and drape subclavian/jugular area. Sterile gloves should

be worn.

ο Subclavian line.

♦ With an index finger placed at the sternal notch, the

thumb is placed at the junction of the medial and middle

third of the clavicle.

♦ 1% lidocaine is infiltrated into the skin, subcutaneous

tissue and periosteum of the clavicle.
8.2

Emergency War Surgery

♦ Introduce a large caliber needle with attached 5 mL

syringe. Insert with the bevel of the needle up, directing

the needle towards the contralateral clavicular head.

Keep the needle horizontal to avoid a pneumothorax.

♦ While aspirating, slowly advance the needle underneath

the clavicle.

ο Jugular vein line.

♦ Turn the patient’s head 45° toward the contralateral side

to expose the neck.

♦ Identify the apex of the anterior cervical triangle formed

by the heads of the sternocleidomastoid muscle to locate

the carotid artery.

♦ Palpate the carotid artery and stay lateral with your

venipuncture.

♦ Introduce a large-bore needle on 10mL syringe at a 45°

angle into the apex of the triangle, lateral to the carotid

pulse.

♦ Carotid Puncture: Immediately withdraw the needle

and place pressure on site for a minimum of 5 minutes.

♦ Advance the needle caudally, parallel to the sagittal

plane and at a 30° posterior angle (eg, toward the

ipsilateral nipple).

♦ When free flow of venous blood appears, advance the

needle an additional 4 mm (the length of the needle

bevel), then remove the syringe and quickly cover the

hub of the needle to prevent air embolism.

◊ If air or arterial blood appears, stop immediately.

Withdraw needle immediately and place pressure at

the site for at least 5 minutes.

♦ If no venous blood return after advancing 5 cm, slowly

withdraw the needle while aspirating. If this fails,

redirect the needle.

ο Subclavian vein or internal jugular vein catheter insertion.

♦ Once the needle is in the vein, introduce the “J” wire

through the needle (Seldinger technique). The wire

should pass with minimal resistance. If wire does not

pass easily, withdraw the entire apparatus and

reattempt line placement.

♦ Remove the needle.
8.3

Vascular Access

♦ Enlarge the puncture site with a scalpel and dilator.

♦ Pass the catheter over the wire while holding the wire in

place, to a depth of 18 cm on the left and 15 cm on the right

for subclavian, and to a depth of 9 cm on the right and 12

cm on the left for jugular vein, then remove the wire.

♦ Aspirate from all ports, flush all ports, suture in place,

apply antibiotic ointment, dress area, secure tubing, and

label date of insertion.

♦ Chest radiograph to ensure line position and rule out

pneumothorax.

Greater Saphenous Vein Cutdowns

 Contraindications.

ο Deep vein thrombosis (DVT) or severe ipsilateral lower

extremity trauma.

 Procedure.

ο Expose, prep, and drape ankle or femoral site.

ο For ankle, administer local anesthetic proximal to the

medial malleolus.

ο Make a superficial transverse incision through the skin

over the entire width of the flat tibial edge (~3cm) in the

area of the saphenous vein.

ο Using a curved hemostat, isolate the greater saphenous

vein from the nerve and underlying bone.

ο Using the open hemostat as a platform, cut a 1–2 mm

venotomy in the anterior surface of the vein with a number

11 blade (Fig. 8-1a).

ο Place the intravenous tubing (previously beveled) or

angiocatheter at least 4 cm into the vein (may require use

of a vein introducer) (Fig. 8-1b).

ο Secure the catheter with a proximal silk ligature, and tie

off the distal vein.

ο Secure the catheter with a suture.

ο Apply a clean dressing.

ο Femoral procedure is essentially the same, with site being

a handbreadth below the inguinal ligament, medial to the

midline of the thigh. After skin incision, finger bluntly

dissects through the fat to the fascia. Hook the finger and

lift, and the vein comes up with it.
8.4

Emergency War Surgery

 Cutdown can also be performed on the common femoral

veins, the jugular veins, and on veins of the forearm.

IO Infusion

 Contraindications.

ο Trauma or infection at insertion site.

ο Recent IO device at the same site.

ο Fracture of insertion bone.

ο Recent sternotomy.

 Devices/ Procedure.

ο F.A.S.T. 1, BIG, SurFast, Jamshidi Needle, VidaPort.

ο Procedures vary based on model; all IV fluids acceptable

except possibly hypertonic solutions.

ο BIG, SurFast, and Jamshidi may be placed in proximal

medial tibia, distal medial tibia, or the radius.

ο F.A.S.T. 1 is designed for sternal placement, 1.5 cm below

the sternal notch.

ο Pediatric: Insert a bone-marrow aspiration needle or 14–

19-gauge spinal needle, directing it caudally through the

outer cortex. Common sites: tibia, distal femur.

ο Aspirate to confirm placement.

a b

Fig. 8-1a,b. Saphenous vein cutdown.