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EJ and Scalp Vein Cannulation in Infants
Question# 953
I am wondering if you can provide clarification as I have heard conflicting responses from different CME attendees. Can you please confirm if ACPs are authorized to initiate scalp and external jugular IVs in neonatal/pediatric patients. Thank you!
Answer:
External Jugular access is considered a peripheral cannulation and as such remains in the ACP scope of practice however should be considered only where other peripheral sites have been considered and failed and typically only in cardiac arrest.
As found in the companion document - "External jugular access, while not stated in the directives, remains in the ACP scope of practice and is typically reserved for cardiac arrest."
While published data suggests low rates of serious complications with EJ cannulation, there is very limited safety data with regards to the prehospital cannulation of the external jugular vein in children. Virtually all published safety data is generated from pediatric emergency departments, pediatric ICUs, or pediatric surgical centers where the providers would have significantly more experience with the procedure than paramedics. Considering this, paramedics should use particular caution when performing this procedure considering the risk of carotid artery puncture or pneumothorax if the procedure is unsuccessful.
Given paramedic familiarity and ease of use intraosseous access may be preferred over EJ cannulation in an emergency when other peripheral sites have failed.
With regards to scalp vein cannulation in infants or neonates. Scalp veins can be a viable option for peripheral cannulation in neonates or infants up to around 10 months of age but are not recommended by any major association for use in emergencies or resuscitation. Both the AHA and AAP recommend conventional peripheral access, umbilical vein cannulation (out of paramedic scope), or intraosseous access for use in emergencies. Similar to EJ cannulation in infants there is no reliable safety data with regards to prehospital cannulation of scalp veins in infants, all research is based in pediatric centers or emergency departments with expert staff and significant resources and optimized environments.
Paramedics should strongly consider cannulation of a peripheral vein on an extremity or IO access in an emergency prior to considering cannulation of a scalp vein.
As found in the companion document - "External jugular access, while not stated in the directives, remains in the ACP scope of practice and is typically reserved for cardiac arrest."
While published data suggests low rates of serious complications with EJ cannulation, there is very limited safety data with regards to the prehospital cannulation of the external jugular vein in children. Virtually all published safety data is generated from pediatric emergency departments, pediatric ICUs, or pediatric surgical centers where the providers would have significantly more experience with the procedure than paramedics. Considering this, paramedics should use particular caution when performing this procedure considering the risk of carotid artery puncture or pneumothorax if the procedure is unsuccessful.
Given paramedic familiarity and ease of use intraosseous access may be preferred over EJ cannulation in an emergency when other peripheral sites have failed.
With regards to scalp vein cannulation in infants or neonates. Scalp veins can be a viable option for peripheral cannulation in neonates or infants up to around 10 months of age but are not recommended by any major association for use in emergencies or resuscitation. Both the AHA and AAP recommend conventional peripheral access, umbilical vein cannulation (out of paramedic scope), or intraosseous access for use in emergencies. Similar to EJ cannulation in infants there is no reliable safety data with regards to prehospital cannulation of scalp veins in infants, all research is based in pediatric centers or emergency departments with expert staff and significant resources and optimized environments.
Paramedics should strongly consider cannulation of a peripheral vein on an extremity or IO access in an emergency prior to considering cannulation of a scalp vein.