Use ultrasound imaging to help identify deep and nonpalpable veins that can accommodate the placement of an IV catheter. Doppler color flow is used to differentiate the brachial artery from other anatomical structures.
Subtitles
<p begin="00:00:14.952" end="00:00:16.649" style="s2">- [Voiceover] Hello,<br />my name is Phil Perera,</p>
<p begin="00:00:16.649" end="00:00:18.425" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:18.425" end="00:00:21.353" style="s2">at the New York Presbyterian<br />Hospital in New York City,</p>
<p begin="00:00:21.353" end="00:00:24.020" style="s2">and welcome to SoundBytes Cases.</p>
<p begin="00:00:25.215" end="00:00:26.601" style="s2">It's today's module, we'll look at the use</p>
<p begin="00:00:26.601" end="00:00:30.339" style="s2">of bedside ultrasound to<br />help us place peripheral IVs.</p>
<p begin="00:00:30.339" end="00:00:32.077" style="s2">Specifically, we'll look<br />at ultrasound guidance</p>
<p begin="00:00:32.077" end="00:00:35.327" style="s2">for cannulation of deep arm veins.</p>
<p begin="00:00:35.327" end="00:00:37.788" style="s2">Ultrasound can allow us<br />to cannulate nonpalpable</p>
<p begin="00:00:37.788" end="00:00:40.505" style="s2">arm veins, which have<br />traditionally been off-limits</p>
<p begin="00:00:40.505" end="00:00:43.292" style="s2">using traditional palpation techniques.</p>
<p begin="00:00:43.292" end="00:00:46.089" style="s2">Thus we can avoid central<br />venous access in those</p>
<p begin="00:00:46.089" end="00:00:48.255" style="s2">with poor traditional<br />access in whom we can get</p>
<p begin="00:00:48.255" end="00:00:50.870" style="s2">a peripheral IV using ultrasound.</p>
<p begin="00:00:50.870" end="00:00:52.739" style="s2">Ultrasound allows precise determination</p>
<p begin="00:00:52.739" end="00:00:55.309" style="s2">of vascular anatomy prior<br />to a puncture attempt,</p>
<p begin="00:00:55.309" end="00:00:57.051" style="s2">and there's been a number<br />of research studies</p>
<p begin="00:00:57.051" end="00:00:59.142" style="s2">that have shown a decrease<br />in number of attempts</p>
<p begin="00:00:59.142" end="00:01:03.217" style="s2">and time to successful<br />cannulation using ultrasound.</p>
<p begin="00:01:03.217" end="00:01:04.592" style="s2">Here's an illustration showing the anatomy</p>
<p begin="00:01:04.592" end="00:01:07.181" style="s2">of the arm veins: a long<br />axis view to the right,</p>
<p begin="00:01:07.181" end="00:01:09.309" style="s2">and a short axis view to the left.</p>
<p begin="00:01:09.309" end="00:01:11.022" style="s2">Note here on the long axis view,</p>
<p begin="00:01:11.022" end="00:01:13.052" style="s2">the brachial artery running down the arm,</p>
<p begin="00:01:13.052" end="00:01:14.668" style="s2">and adjacent to the brachial artery,</p>
<p begin="00:01:14.668" end="00:01:16.926" style="s2">we can see here the brachial vein.</p>
<p begin="00:01:16.926" end="00:01:19.271" style="s2">Notice that the brachial<br />vein is composed of</p>
<p begin="00:01:19.271" end="00:01:22.125" style="s2">two major veins: the<br />basilic vein, which is the</p>
<p begin="00:01:22.125" end="00:01:25.578" style="s2">larger vein located more<br />superficially and medially,</p>
<p begin="00:01:25.578" end="00:01:27.606" style="s2">and the deep brachial veins found</p>
<p begin="00:01:27.606" end="00:01:29.548" style="s2">adjacent to the brachial artery,</p>
<p begin="00:01:29.548" end="00:01:33.224" style="s2">in a deeper and more<br />lateral position on the arm.</p>
<p begin="00:01:33.224" end="00:01:34.472" style="s2">Let's look at the short axis view,</p>
<p begin="00:01:34.472" end="00:01:37.151" style="s2">and here we can see well<br />the brachial complex:</p>
<p begin="00:01:37.151" end="00:01:38.964" style="s2">the brachial artery surrounded by</p>
<p begin="00:01:38.964" end="00:01:41.878" style="s2">two deep brachial veins here,<br />and the more superficial</p>
<p begin="00:01:41.878" end="00:01:44.484" style="s2">and medial basilic vein, which is really</p>
<p begin="00:01:44.484" end="00:01:48.254" style="s2">the preferred target for a<br />deep ultrasound guided IV.</p>
<p begin="00:01:48.254" end="00:01:50.325" style="s2">Note the median nerve lying on top of</p>
<p begin="00:01:50.325" end="00:01:52.358" style="s2">the deep brachial vein,<br />which must be avoided</p>
<p begin="00:01:52.358" end="00:01:55.783" style="s2">during a puncture attempt<br />on this structure.</p>
<p begin="00:01:55.783" end="00:01:57.171" style="s2">Here's a picture showing<br />the surface anatomy</p>
<p begin="00:01:57.171" end="00:01:59.206" style="s2">of the veins of the upper arm.</p>
<p begin="00:01:59.206" end="00:02:01.764" style="s2">Notice here the basilic vein<br />in a more medial position</p>
<p begin="00:02:01.764" end="00:02:05.084" style="s2">on the patient's arm, and<br />the brachial vein complex,</p>
<p begin="00:02:05.084" end="00:02:07.017" style="s2">which would be located more laterally</p>
<p begin="00:02:07.017" end="00:02:09.077" style="s2">on the patient's arm.</p>
<p begin="00:02:09.077" end="00:02:10.624" style="s2">And these are the positions over which</p>
<p begin="00:02:10.624" end="00:02:12.510" style="s2">we should place the probe in order to</p>
<p begin="00:02:12.510" end="00:02:15.409" style="s2">inspect the veins of the upper arm.</p>
<p begin="00:02:15.409" end="00:02:17.314" style="s2">Here are the orientations in which we can</p>
<p begin="00:02:17.314" end="00:02:18.893" style="s2">place the probe to inspect the vein</p>
<p begin="00:02:18.893" end="00:02:21.106" style="s2">for vascular line placement.</p>
<p begin="00:02:21.106" end="00:02:23.016" style="s2">We see the short axis view to the left.</p>
<p begin="00:02:23.016" end="00:02:24.465" style="s2">And notice that we're placing the probe</p>
<p begin="00:02:24.465" end="00:02:26.533" style="s2">perpendicular to the vein, and note that</p>
<p begin="00:02:26.533" end="00:02:28.452" style="s2">the resulting ultrasound image of the vein</p>
<p begin="00:02:28.452" end="00:02:31.527" style="s2">will appear as a circle,<br />as the vascular structure,</p>
<p begin="00:02:31.527" end="00:02:34.389" style="s2">the vein here, will be cut end on.</p>
<p begin="00:02:34.389" end="00:02:36.252" style="s2">Note the long axis view to the right</p>
<p begin="00:02:36.252" end="00:02:39.164" style="s2">in which the probe is placed<br />in a longitudinal manner</p>
<p begin="00:02:39.164" end="00:02:41.128" style="s2">along the course of the vein, and note</p>
<p begin="00:02:41.128" end="00:02:42.911" style="s2">the resulting image of the vein,</p>
<p begin="00:02:42.911" end="00:02:44.410" style="s2">which appears as a tubular structure</p>
<p begin="00:02:44.410" end="00:02:46.447" style="s2">on the ultrasound screen.</p>
<p begin="00:02:46.447" end="00:02:48.820" style="s2">Here's the high-frequency,<br />linear type of ray probe</p>
<p begin="00:02:48.820" end="00:02:51.005" style="s2">that we'll be using for vascular access.</p>
<p begin="00:02:51.005" end="00:02:53.150" style="s2">And that line on the side<br />is the indicator marker</p>
<p begin="00:02:53.150" end="00:02:54.233" style="s2">on the probe.</p>
<p begin="00:02:55.412" end="00:02:57.345" style="s2">Here's the high-frequency,<br />linear type of ray probe</p>
<p begin="00:02:57.345" end="00:02:59.264" style="s2">placed on the patient's upper arm.</p>
<p begin="00:02:59.264" end="00:03:01.277" style="s2">Notice here that it's<br />placed in a short axis,</p>
<p begin="00:03:01.277" end="00:03:04.164" style="s2">or side-to-side configuration.</p>
<p begin="00:03:04.164" end="00:03:05.574" style="s2">Here we have the probe positioned over</p>
<p begin="00:03:05.574" end="00:03:08.498" style="s2">the more medial, basilic vein.</p>
<p begin="00:03:08.498" end="00:03:10.412" style="s2">Notice also that the probe marker here</p>
<p begin="00:03:10.412" end="00:03:13.321" style="s2">is towards our left as we<br />stand in front of the patient,</p>
<p begin="00:03:13.321" end="00:03:15.277" style="s2">and the reason for that<br />is note on the screen</p>
<p begin="00:03:15.277" end="00:03:19.053" style="s2">that the indicator dot is<br />also located here to the left.</p>
<p begin="00:03:19.053" end="00:03:21.510" style="s2">Therefore left on the probe lines up</p>
<p begin="00:03:21.510" end="00:03:23.510" style="s2">with left on the screen.</p>
<p begin="00:03:24.543" end="00:03:26.093" style="s2">So now that we know the<br />proper configuration</p>
<p begin="00:03:26.093" end="00:03:27.929" style="s2">of the probe in the short axis view,</p>
<p begin="00:03:27.929" end="00:03:29.689" style="s2">let's take a look at a typical appearance</p>
<p begin="00:03:29.689" end="00:03:32.352" style="s2">of vascular structures cut end on.</p>
<p begin="00:03:32.352" end="00:03:33.976" style="s2">Here we have the probe positioned over</p>
<p begin="00:03:33.976" end="00:03:35.748" style="s2">the brachial complex, and we see here</p>
<p begin="00:03:35.748" end="00:03:38.061" style="s2">the central brachial artery, surrounded by</p>
<p begin="00:03:38.061" end="00:03:40.638" style="s2">two deep brachial veins.</p>
<p begin="00:03:40.638" end="00:03:42.857" style="s2">So let's put that into video play here,</p>
<p begin="00:03:42.857" end="00:03:44.554" style="s2">and notice with compression that</p>
<p begin="00:03:44.554" end="00:03:47.055" style="s2">both of the veins compress completely,</p>
<p begin="00:03:47.055" end="00:03:49.202" style="s2">helping us differentiate venus structures</p>
<p begin="00:03:49.202" end="00:03:51.183" style="s2">from the artery in the center.</p>
<p begin="00:03:51.183" end="00:03:53.946" style="s2">And notice that the artery<br />has less distensible walls,</p>
<p begin="00:03:53.946" end="00:03:58.113" style="s2">and stays open, even as we<br />compress down with the probe.</p>
<p begin="00:03:59.082" end="00:04:00.956" style="s2">We can further differentiate<br />vascular structures</p>
<p begin="00:04:00.956" end="00:04:03.232" style="s2">by applying color doppler flow.</p>
<p begin="00:04:03.232" end="00:04:04.952" style="s2">Notice here as we apply doppler,</p>
<p begin="00:04:04.952" end="00:04:06.920" style="s2">that we see arterial pulsations</p>
<p begin="00:04:06.920" end="00:04:09.229" style="s2">in the central brachial artery.</p>
<p begin="00:04:09.229" end="00:04:11.356" style="s2">However notice the<br />absence here of any flow</p>
<p begin="00:04:11.356" end="00:04:13.069" style="s2">within the deep brachial veins,</p>
<p begin="00:04:13.069" end="00:04:14.687" style="s2">and that's because of the slightest flow</p>
<p begin="00:04:14.687" end="00:04:16.924" style="s2">within those two vascular structures</p>
<p begin="00:04:16.924" end="00:04:18.926" style="s2">as compared to the brisk arterial flow</p>
<p begin="00:04:18.926" end="00:04:22.336" style="s2">in the central brachial artery.</p>
<p begin="00:04:22.336" end="00:04:24.763" style="s2">So putting it all together,<br />using doppler flow</p>
<p begin="00:04:24.763" end="00:04:27.822" style="s2">and applying compression,<br />notice here again</p>
<p begin="00:04:27.822" end="00:04:30.406" style="s2">that the brachial artery<br />in the center stays open</p>
<p begin="00:04:30.406" end="00:04:33.442" style="s2">and has brisk arterial pulsations.</p>
<p begin="00:04:33.442" end="00:04:35.087" style="s2">And notice that the two flanking</p>
<p begin="00:04:35.087" end="00:04:37.206" style="s2">deep brachial veins compress completely</p>
<p begin="00:04:37.206" end="00:04:41.373" style="s2">and have a lack of vascular<br />flow with doppler interrogation.</p>
<p begin="00:04:42.482" end="00:04:44.167" style="s2">Now let's look at a video clip that shows</p>
<p begin="00:04:44.167" end="00:04:45.803" style="s2">all of the veins of the upper arm</p>
<p begin="00:04:45.803" end="00:04:47.701" style="s2">in relation to one another.</p>
<p begin="00:04:47.701" end="00:04:50.822" style="s2">Medial is to the right,<br />and lateral is to the left.</p>
<p begin="00:04:50.822" end="00:04:53.864" style="s2">Here we see the larger and<br />more superficial basilic vein,</p>
<p begin="00:04:53.864" end="00:04:57.742" style="s2">more medial and superficial<br />to the brachial complex,</p>
<p begin="00:04:57.742" end="00:04:59.862" style="s2">which is located here to the left.</p>
<p begin="00:04:59.862" end="00:05:01.320" style="s2">And note the central brachial artery,</p>
<p begin="00:05:01.320" end="00:05:04.226" style="s2">and two flanking deep brachial veins.</p>
<p begin="00:05:04.226" end="00:05:06.114" style="s2">In this patient, the basilic vein would be</p>
<p begin="00:05:06.114" end="00:05:09.393" style="s2">the preferred target for<br />placement of a deep arm IV.</p>
<p begin="00:05:09.393" end="00:05:10.890" style="s2">Here's a different patient.</p>
<p begin="00:05:10.890" end="00:05:12.189" style="s2">Again, we're looking at the relation</p>
<p begin="00:05:12.189" end="00:05:15.130" style="s2">of the basilic vein to<br />the brachial complex.</p>
<p begin="00:05:15.130" end="00:05:18.135" style="s2">Medial is to the left, and<br />lateral is to the right.</p>
<p begin="00:05:18.135" end="00:05:20.412" style="s2">We see here the superficial basilic vein,</p>
<p begin="00:05:20.412" end="00:05:22.651" style="s2">and the deeper brachial complex.</p>
<p begin="00:05:22.651" end="00:05:25.390" style="s2">Notice we apply pressure, that<br />all of the venus structures-</p>
<p begin="00:05:25.390" end="00:05:27.925" style="s2">the basilic vein, and<br />the deep brachial veins,</p>
<p begin="00:05:27.925" end="00:05:30.628" style="s2">all compress completely,<br />helping us differentiate</p>
<p begin="00:05:30.628" end="00:05:33.738" style="s2">venus from arterial vascular structures.</p>
<p begin="00:05:33.738" end="00:05:36.257" style="s2">Here we're applying doppler flow,</p>
<p begin="00:05:36.257" end="00:05:38.581" style="s2">and again we can differentiate<br />the brachial artery</p>
<p begin="00:05:38.581" end="00:05:42.208" style="s2">by its pulsations consistent<br />with arterial flow.</p>
<p begin="00:05:42.208" end="00:05:43.973" style="s2">And note the lack of significant flow</p>
<p begin="00:05:43.973" end="00:05:45.700" style="s2">within the venus structures.</p>
<p begin="00:05:45.700" end="00:05:47.930" style="s2">Specifically, the basilic vein.</p>
<p begin="00:05:47.930" end="00:05:49.701" style="s2">Here's the high-frequency,<br />linear type of ray probe</p>
<p begin="00:05:49.701" end="00:05:52.672" style="s2">in a longitudinal, or<br />long access orientation</p>
<p begin="00:05:52.672" end="00:05:54.492" style="s2">over the patient's upper arm.</p>
<p begin="00:05:54.492" end="00:05:58.644" style="s2">Here it's located over the<br />more medial, basilic vein.</p>
<p begin="00:05:58.644" end="00:06:00.829" style="s2">In this orientation, we<br />have the probe marker</p>
<p begin="00:06:00.829" end="00:06:03.421" style="s2">going distally, and this<br />helps us line up the probe</p>
<p begin="00:06:03.421" end="00:06:05.763" style="s2">with regard to the screen.</p>
<p begin="00:06:05.763" end="00:06:07.594" style="s2">Notice the screen indicator dot here</p>
<p begin="00:06:07.594" end="00:06:09.882" style="s2">is located towards the left, therefore,</p>
<p begin="00:06:09.882" end="00:06:13.751" style="s2">distal on the screen would<br />be over towards the left,</p>
<p begin="00:06:13.751" end="00:06:15.891" style="s2">and the proximal on the screen</p>
<p begin="00:06:15.891" end="00:06:18.513" style="s2">would be located over towards the right.</p>
<p begin="00:06:18.513" end="00:06:20.876" style="s2">Here's a typical appearance<br />of a venus structure</p>
<p begin="00:06:20.876" end="00:06:24.595" style="s2">cut in a longitudinal,<br />or long axis orientation.</p>
<p begin="00:06:24.595" end="00:06:26.827" style="s2">Notice here that the vein<br />has more of a tubular</p>
<p begin="00:06:26.827" end="00:06:29.558" style="s2">appearance on the screen, and<br />that the flow of blood here</p>
<p begin="00:06:29.558" end="00:06:31.979" style="s2">is from the left, which<br />is distal on the vein,</p>
<p begin="00:06:31.979" end="00:06:35.729" style="s2">towards the right, which<br />is proximal on the vein.</p>
<p begin="00:06:35.729" end="00:06:38.213" style="s2">Looking in long axis gives<br />complementary information</p>
<p begin="00:06:38.213" end="00:06:39.463" style="s2">about the vein.</p>
<p begin="00:06:40.540" end="00:06:42.228" style="s2">So thanks for tuning in to part one of</p>
<p begin="00:06:42.228" end="00:06:45.676" style="s2">ultrasound guided peripheral IV insertion.</p>
<p begin="00:06:45.676" end="00:06:47.816" style="s2">As we mentioned, ultrasound<br />can be very helpful</p>
<p begin="00:06:47.816" end="00:06:50.385" style="s2">in identifying deeper<br />and nonpalpable veins</p>
<p begin="00:06:50.385" end="00:06:53.982" style="s2">that can still allow placement<br />of intravenous catheter.</p>
<p begin="00:06:53.982" end="00:06:56.044" style="s2">We'll be looking at the vein in both short</p>
<p begin="00:06:56.044" end="00:06:58.168" style="s2">and long axis views to<br />determine the anatomy</p>
<p begin="00:06:58.168" end="00:07:00.862" style="s2">prior to a puncture attempt.</p>
<p begin="00:07:00.862" end="00:07:02.754" style="s2">And now that we have a good sense in terms</p>
<p begin="00:07:02.754" end="00:07:05.622" style="s2">of how to look at a vein in<br />both short and long axis,</p>
<p begin="00:07:05.622" end="00:07:07.302" style="s2">we're ready to move directly to learning</p>
<p begin="00:07:07.302" end="00:07:10.102" style="s2">how to cannulate the<br />vein using ultrasound.</p>
<p begin="00:07:10.102" end="00:07:12.308" style="s2">So I look forward to<br />seeing you in part two</p>
<p begin="00:07:12.308" end="00:07:14.641" style="s2">of peripheral venous access.</p>