ATLS: difficult venous access

If intravenous cannulae cannot be inserted via the percutaneous route into the antecubital fossae, other sites must be considered i.e. external jugular vein or veins in the feet.

If access cannot be gained within 5 minutes and the patient is shocked, then further measures should be taken until access is gained. Note that a line should not be placed distal to a severe injury. Sites for cannulation include:

• cut-down in the antecubital fossa - safest, most effective site
• cut-down to the long saphenous vein in the groin, rather than at the ankle, as intense vasospasm may prevent infusion
• percutaneous cannulation of the femoral vein - using the Seldinger technique
• percutaneous cannulation of neck veins using Seldinger technique
• intra-osseous infusion in a severely ill child