Ultrasound-Guided PIV Placement Part 2 POD

jonas pologe · September 14, 2018 · Procedures, Ultrasound

The following is a powerful advanced technique that can be used to troubleshoot traditional short-axis US-PIV placement.

A familiar scenario: The elusive needle tip!

You’re placing an US-guided PIV and going ahead with your short axis technique
The vessel is directly under the center of the probe, right on that Bx-guide line
You know exactly how deep it is
The needle has entered the skin… the tip should be right over or very near the vessel…
But where is it??? You’re bouncing the needle a little and see tissue moving, you’re slowly sweeping the probe backward and forward where your needle tip should be, but it continues to elude you! Maybe it’s a little deep, maybe there’s some echogenic (bright) tissue hiding it, doesn’t matter, here’s what to do...

The answer: Long Axis — Hear me out!

Take your eyes off of the ultrasound screen
Pick up the probe and place it back down, marker toward you, exactly along the axis of the angiocath, DIRECTLY over it!
Without moving your hand, look back up at the screen. Unless you’re at a crazy steep angle, you will see your whole needle clearly!
If you see the vessel on the screen as well, you are now perfectly set up to continue placing your IV
Position the tip in the vessel lumen, then advance the angiocath over the needle as you normally would

Image result for long axis ultrasound guided IV

The other scenario: You’ve positioned the probe over the needle, you look up and see the needle but not the vessel any more, or maybe part of the vessel — here’s what you do

Slide/rotate the probe such that you have the vessel in view at its widest diameter on the screen
Then LOOK BACK AT THE ARM
If the probe is now to the right of the needle, you need to redirect to the right; if the probe is to the left, the needle needs to go left
Withdraw the needle a few mm and then redirect so that it is inline with the ultrasound
As you do this, look back up at the screen and you should see the needle coming into view

In a nutshell: If you’ve lost your needle tip

1. Use the probe to show you where the needle is

2. Use the probe to show you where the vessel is

3. With the probe over the vessel, position the needle so that it’s directly under the probe

4. Now all three are lined up and you’re ready to position the needle tip in the vessel lumen

A few last tips:

You can fine-tune your left-right control of needle tip in long axis by just moving the needle slightly one way or the other and seeing if it comes more into view or less into view — this will start happening automatically if you practice this technique a few times
I still recommend letting go of the probe and advancing the angiocath with non-dominant hand, however if an assistant takes the probe when you are ready to advance the angiocath, you can watch it go into the vessel and ensure that it is advancing smoothly into the lumen.
You can do this with one person as well but this requires advancing the angiocath and stabilizing the needle with one hand, which is more difficult and gives little tactile feedback as to whether it is advancing smoothly or meeting resistance
Once you’re comfortable with this long-axis technique, try doing the entire procedure in long axis. This tends to work very well for deeper, straighter veins.
There’s no reason you can’t switch back to short once you’ve found your needle tip and repositioned it; perhaps it’s a twisty vessel with multiple turns and you need to walk it in a little more - short axis is better for navigating in the left-right direction (as long as you’ve located your needle tip!)
Remember the concept of "angle of insonation": the steeper your needle angle, the more difficult it will be to see your needle because fewer ultrasound beams are bouncing back to the probe (more are being deflected in a different direction)

Jonas Pologe, PGY3, Emergency Medicine, Maimonides Medical Center

Superficial Cervical Plexus Block POD

jonas pologe · September 7, 2018 · Ultrasound, Procedures

That’s right. Time to talk about my favorite nerve block.

The SCPB

This block is

quick

and

easy

It makes

IJ central lines

painless procedures

It also provides excellent analgesia for

clavicle fractures

ear lobe lacerations

blind subclavian lines

, or

anything within this quadrilateral

How to do it

Find the

posterior aspect of the sternocleidomastoid (SCM) muscle

Position the probe half way down the SCM as you measure it from mastoid process to clavicle.

About at the level of the superior aspect of the thyroid cartilage, also about where the EJ crosses over the sternocleidomastoid.

The fascial plane under the posterior aspect of the sternocleidomastoid muscle is your target.

Like other

plane blocks

you are not targeting any one nerve in particular. By infiltrating this tissue plane, you get the superficial plexus as it peeks out from behind the SCM at this level:

Inject 5-10 cc of local anesthetic.

Ensure it is spreading in the plane like this.

Safety:

As with all ultrasound guided nerve blocks, visualize your needle tip always, especially prior to injection.
When you begin injecting, inject one mL only to ensure you see it spreading in the fascial plane. Then inject the rest.
Withdraw before you inject if there is even a slight possibility you are close to a vessel
Throw some color on your site to ensure you identify any vessels.
In general this is a very well tolerated and forgiving block.
The incidence of phrenic nerve involvement is extremely low with SCPB, far lower than with the interscalene block. Phrenic nerve involvement will be avoided if ensure you don’t go too deep - a few cm, or about half way down the deep edge of the SCM. Going deeper than this results in a deep cervical plexus block which will result in some motor and sensory blockade of the arm.
Horner’s syndrome is a rare and self-limiting complication.
The amount of local anesthetic used in this block is nowhere near close to toxic levels, so local anesthetic systemic toxicity will not occur as long as you manage to avoid the IJ and carotid.

Tips and troubleshooting

For a central line, you can set up, gown, drape, and set up your ultrasound like usual, then use the 5 cc lidocaine which come in the central line kit for your block. Place the block first, then flush your line/lay out your equipment, and your patient will likely be completely numb by the time you’re ready to start your line placement.
The other option is to place your block while you’re doing your pre-scan. This way you can use 5-10 cc, but you have to get it out of the Pyxis. Just clean the probe and the skin with a chlorhexidine swab and use sterile gel.
If it’s your first time doing a block, consider doing it as a 2 person block. Use some IV extender tubing and have another provider operate the syringe for you. I like slightly longer tubing than typical IV tubing, e.g. the one below. At Maimo, you can find it in the stock room between North and South sides, top shelf straight ahead when you first walk in.
Can't visualize your needle? Make sure your ultrasound probe is directly above it and in-line with it. Next, make sure it is as close to parallel to the surface of the probe/perpendicular to the ultrasound beams as possible. If you are approaching a 45 degree angle, your needle will be close to invisible. At close to a 0 degree angle, it will shine like a laser beam.
You can use the 27 gauge needles to make it more comfortable but they are a little harder to see.

Cordis Placement POD

jonas pologe · August 27, 2018 · Procedures

Today’s Pearl of the Day is onCordis Placement! This topic is geared more toward our interns and second-years who have less experience in big trauma (have not yet rotated at Shock).

The

cordis is the preferred central line in trauma

, unstable GI bleeds, ruptured AAAs, or any other situation in which the necessity for rapid transfusion of blood products is anticipated. It is a short, wide, single-lumen central venous catheter that is perfect for rapid large-volume infusions.

The kit looks like this.

(The kit in the picture above also has a sterile sleeve for transvenous pacer placement, but that plays no role in cordis placement for resuscitation).

Here it is with all the components taken out, in order of use.

Note that when you first open the kit, the dilator sits BACKWARDS in the cordis catheter.

So the first step in setting up for this line is to take the dilator out of the front end of the cordis and place it in the back end of the cordis so it looks like this.

Flush the line (unless you need to draw blood off of it immediately) and lock it so it doesn’t bleed everywhere.

The rest of cordis placement is fairly straightforward.

Cordis placement: wire in, dilator-cordis in, wire and dilator out (while cordis catheter stays in).

Contrast that with

triple lumen catheter placement: wire in, dilator in, dilator out, triple lumen catheter in, wire out (while triple lumen catheter stays in).

For a more detailed explanation of cordis placement, READ ON!

By this point the patient has already been prepped/draped/anesthetized (if time permits).

The next step is to

get your wire into the vessel

. To achieve this you can either use the wire-through-needle technique or wire-through-catheter technique. For a review of the wire through catheter technique, please see Dr. Strayer’s video on this topic:

https://vimeo.com/133254469

I will focus on the wire through needle technique in this guide.. Note that this kit has a special

blue syringe: the introducer syringe.

It has a hole in the back of the plunger that allows you to advance the needle directly through the syringe and out the needle. Using this feature allows you to skip the step of taking the syringe off the needle which can lead to the needle slipping out of the vessel.

If using ultrasound, note depth of vessel, position in center of ultrasound screen, visualize vessel, and advance needle tip directly into the center of the vessel (see my PIV POD email/Maimo Blog post

http://mmcedrco.w02.wh-2.com/EMBlog/2018/08/23/

for description of this technique).

If using landmarks (this guide will focus on the femoral vein site), place a thumb on the pubic symphysis and index finger on ASIS. The line between them is the inguinal ligament. Half-way between them is the femoral artery and 1cm more medial is the femoral vein.

If you can’t remember which side the vein is on, remember “

venous is toward the penis

”. The

puncture site should be 1-2cm distal to the inguinal ligament

If the artery is palpable, enter 1cm medial to it. If it isn’t easily palpable, enter just above the webspace between your thumb and index finger as they are positioned on pubic symphysis and ASIS respectively.

Always aspirate the plunger while you advance.

Once you get flash, keep needle/syringe perfectly still in non-dominant hand braced on patient. Check once more that blood can be aspirated, then reach for wire with your dominant hand;

advance wire through syringe

(assuming you’re using the blue introducer syringe). It should advance smoothly. If it doesn’t, take out the wire, check that blood is still easily aspirated, reposition or drop your angle as needed and try to advance wire again.

Wire is now in place.

Needle/syringe are removed

over the wire. Make a

skin-nick with the scalpel

in the direction of the wire.

Advance the dilator-cordis-unit over the wire

, stabilizing the wire from behind the dilator-cordis with your non-dominant hand and advancing the dilator-cordis with your dominant hand.

Advance sequentially with small twisting motions

always

gripping the cordis close to the skin

, until it is “hubbed” (cannot advance any further).

Wire comes out, then dilator comes out.

(Or wire and dilator can come out together if you can grab them both comfortably). Flush your line, suture in place, cover with sterile dressing kit, and you’re done.

Image credit:

Brown EM Educational Blog Website

(

http://blogs.brown.edu/emergency-medicine-residency/the-central-line-part-2-technique-procedural-steps/)

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