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Establishing reliable vascular access in an emergency situation is of critical importance. Many factors, including body habitus, volume depletion, shock, history of intravenous drug abuse, congenital deformity, and cardiac arrest can make obtaining vascular access in the critically ill or injured patient extremely difficult. The introduction of real-time bedside ultrasound into emergency and acute care settings has been an important advance for facilitating rapid and successful vascular access.
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For central access, the use of an anatomic landmark-guided approach has been the traditional practice. Internal jugular vein location traditionally relies on the sternocleidomastoid muscle and clavicular landmarks; the femoral vein relies on the inguinal ligament and femoral artery pulsation landmarks; and the subclavian vein relies on clavicular landmarks. In many patients, however, these landmarks may be distorted, obscured, or nonexistent. In addition, normal variations in the anatomic relationship of the internal jugular vein may make cannulation difficult.1 In the emergent situation, attempting central vascular access with poor external landmarks is frequently approached using a “best guess” estimate of the vessel location. This may lead to multiple needle passes to locate the vessel. Excessive bleeding, inadvertent arterial puncture, vessel laceration, pneumothorax, and hemothorax are some of the potential complications of central vascular access. The incidence of complications increases when multiple attempts are required for cannulation.2–5 In patients with an underlying coagulopathy (pathologic or therapeutic), multiple attempts can carry significant morbidity due to hemorrhage.6, 7
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The introduction of portable bedside ultrasound has been very effective in assisting with the placement of central venous access catheters. For internal jugular vein cannulation, ultrasound use has been described by numerous disciplines, including emergency medicine, critical care medicine, anesthesiology, obstetrics/gynecology, nephrology, surgery, and radiology.2, 3, 8–10 When compared to the external landmark approach, ultrasound-guided internal jugular vein cannulation results in fewer complications and is more effective in time-to-cannulation and first-attempt success.2, 6, 11–14 For femoral vein cannulation, the ultrasound-guided approach was found to be more successful than the landmark approach in patients presenting in cardiac arrest.15
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Peripheral venous access is less invasive and is used more commonly in the emergency department than central access. The inability to find an adequate peripheral vein generally requires that the clinician consider central venous access. Traditionally, successful peripheral venous cannulation requires that a vein first be visualized or palpated. Some peripheral veins that are not readily apparent on the skin surface can be clearly visualized with the use of ultrasound, which may obviate the need for central access.15, 16 The basilic and cephalic veins of the arm are superficial veins that are not generally visible but are readily cannulated using ultrasound guidance. Basilic vein cannulation has been shown to be very successful in the emergency department setting in patients in whom it was difficult to obtain other peripheral vascular access.17 Basilic vein cannulation is readily learned by novice users.18 In addition, basilic veins have ...