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Attach the saline lock and flush the lock with saline, or attach IV fluid tubing directly to the hub of the catheter. Secure the catheter hub with tape or a commercially available securing device. Check for signs of infiltration (i.e., localized swelling, inability to flush the catheter, pain).

The technique for cannulating the external jugular vein is similar. The needle is inserted in a caudad direction, but no tourniquet is used. Instead, the index finger of the nondominant hand can be used to apply gentle pressure to the external jugular vein just above the clavicle to facilitate venous engorgement. Care should be taken to avoid placing a needle puncture too low in the neck (i.e., at or immediately above the clavicle) to avoid lung injury. Blind attempts when the external jugular vein is not readily apparent are not advised due to potential for serious injury to surrounding structures (Figure 8.5).

Contraindications to intravenous access relate mainly to site selection. Sites with burns, cellulitis, trauma, and other conditions that compromise the integrity of the overlying skin should be avoided. Extremities on the side of a recent mastectomy or lymphatic chain removal, those that contain known thromboses, and those that contain permanent modifications for dialysis access should be used only when all other options have been exhausted. Special consideration must be given to patients with known bleeding disorders and those who are taking medications that may alter coagulation. In such cases, the ability to compress the vein used for an IV attempt is important to limit excessive bleeding.

Figure 8.5 External jugular vein.

Maintenance of vascular access in the prehospital setting may often prove difficult as perspiration, dirt, and water reduce the effectiveness of tape and adhesive dressings used to secure the catheter. Combative or confused patients can also intentionally or unintentionally dislodge their IV access during transport, and may require additional verbal instruction and reminders along with extra padding and support to maintain the line. Gauze wraps, elastic bandages, and arm boards are just a few examples of adjuncts used to protect and optimally position venous access.