Trick of the Trade: Winging It with External Jugular Cannulation

Sankoff J, et al. WJEM (2008)

Imagine yourself caring for a patient that needs urgent vascular access, but several attempts at peripheral intravenous (IV) cannulation have been unsuccessful. You aren’t quite at the point where emergent intraosseous or central venous access is indicated. Maybe those options aren’t even available where you’re working. From across the room, though, you can see a very prominent external jugular (EJ) vein. Sadly, you remember the last EJ line you placed falling out almost immediately.

Patients with challenging peripheral intravenous access in the extremities may require and benefit from cannulation of the EJ. Often done in the setting of resuscitation, securing these angiocatheters on the neck can be difficult. Tape and dressings may not stick due to sweat and anatomical limitations. Rotation, flexion, and extension of the neck can displace the catheter.

Trick of the Trade

If available, modify a winged angiocatheter to allow suturing to the skin of the neck.

• Create two small holes, one on each wing of the angiocatheter, using a sharp instrument such as scissors, scalpel, or needle.
• Place EJ line and secure to the skin using sutures, similar to stabilization of central or arterial line.

Winged angiocatheters may not be available in all clinical institutions. International readers of ALiEM may be more familiar with their use.

However, this trick introduces the idea of finding creative modifications of available catheters to allow for suturing and securing of alternative IV lines. Modifications similar to this Trick of the Trade can be considered when placing “deep” peripheral IVs or pseudo-midline IVs such as when using extended-length angiocatheters or repurposed arterial catheters where suture can be wrapped around the hub. This approach may also be useful in peripheral cannulation of the internal jugular vein. 

Tip: Be careful not to pierce the catheter or compress it down when suturing.

More from ALiEM on EJ cannulation:

• Trick of the trade: You can use your stethoscope as a “tourniquet” for EJ IV placement
• Trick of the trade: You can bend the angle of the angiocatheter if the jaw is in the way
• Trick of the trade: Have the patient hum if they cannot tolerate Trendelenberg to increase venous distension

Interest in other tricks?

Read more articles in the Tricks of the Trade series.