The Blind Internal Jugular Central Catheter

To today's young burgeoning emergency physicians, ultrasound guided internal jugular central catheters have more or less become standard of care.  And for good reason!  They are safe, and after a good amount of experience, quite easy to perform.

But what if you're practicing in those shops that don't have ultrasound? It's hard to imagine in this day and age but it's the truth in some places.  Let's say you're in said department, and a floridly septic patient rolls in.  You fluid resuscitate, but after several liters of fluid their blood pressure remains crappier than crappy.

What's your plan, doctor?  You can start that norepinephrine peripherally to buy you some time (bollocks to dopamine of course), but you're going to need central access.  Femoral lines are easily done blind, but you'll be unable to get CVP's, and the infection risk limits their lifespan.

Some of our colleagues who have been in the game more than a few years often quip, "In my day, we did all these blind, you know...."  Maybe we should take some advice from our wise forbearers and learn a thing or two.....

Clearly, your setup will be the same as it always is, with your kit that includes your local anesthetic, finder needle, wire, dilator, scalpel, suture, and catheter.  And it's still sterile as humanly possible, of course.  To make everyone's life easy, we'll just assume there is no reason you can't use the right IJ and describe the procedure as such.

Your best friend will be your sternocleidomastoid.  Know it like the back of your own sternocleidomastoid!  You can access the IJ either anteriorally, centrally, or posteriorally to this landmark.  To come at it anterior, find where the medial edge of the SCM meets the clavicle, and measure up 2-3 fingerbreaths.  Come in from 30-45 degrees and aim at the nipple.  Generally speaking, this approach carries the highest risk of arterial injury.

To come centrally, identify the triangle formed by the clavicle and the two heads of the SCM.  Your needle will enter at the apex of said triangle at an angle of 30 degrees, also aiming at the ipsilateral nipple.  

Finally, the posterior approach brings you higher up in the neck, decreasing the risk of carotid puncture of pneumothorax.  You'll need to come about halfway up the lateral edge of the SCM, and come in pretty steep at 45 degrees.  Instead of aiming at the nipple, you'll want to come in at the suprasternal notch.  Look out for the EJ on your way in!

The official New England Journal of Medicine video on IJ placement is largely ultrasound driven, but they do have some pretty impressive graphics regarding positioning in an ultrasonagraphically poor world.

Scott Weingart has a demonstration on the EMCrit blog:

This is just part of a fantastic piece on central lines that can be found here.  I highly suggest you check it out.

Just as always, these posts are meant for EDUCATIONAL PURPOSES ONLY.  Are you still only comfortable with doing these with a probe?  Maybe you should go practice on a model first.

Stay tuned--Procedures Club Videos are coming to a website near you!

jps

Sources:

Roberts and Hedges' Clinical Procedures in Emergency Medicine.  Chapter 22.

New England Journal of Medicine Videos in Clinical Medicine.

EMCrit.org

Life in the Fast Lane Website, Central Venous Catheters