Đi xuống làm tăng căng tĩnh mạch và làm giảm nguy cơ của thuyên tắc khí. • 30 độ đi xuống, và quay đầu phía bên tay trái cho các cách tiếp cận mặt phải tránh ống dẫn bạch huyết. Đặt khăn theo vai để mở rộng cổ. • Xác định các đỉnh của tam giác được hình thành bởi hai đầu của sternomastoid và xương đòn và xâm nhập gây tê cục bộ | PROCEDURES AND EQUIPMENT 161 Internal jugular sterile technique Head down increases vein distension and reduces risk of air embolism. 30 degrees head down and turn head to left hand side for the right sided approach which avoids lymphatic duct. Place towel under shoulders to extend neck. Identify apex of triangle formed by two heads of the sternomastoid and clavicle and infiltrate local anaesthetic if conscious . Alternatively identify carotid medial to sternomastoid at level of lower border of thyroid cartilage vein is just lateral to this usually aim needle at 30 degrees to skin and towards the ipsilateral nipple in infants neck is very short and vein is superficial . Estimate the length of catheter from the skin entry to the nipple. Direct needle at 30 degrees to the skin pointing towards the ipsilateral nipple and puncture the skin at the apex of the triangle. Advance needle aspirating. If blood flashes back stop advancing remove syringe. If you do not cannulate vein withdraw the needle but not out of the skin and advance again slightly more laterally Feed the Seldinger guidewire through the needle always holding end of wire. 162 POCKET EMERGENCY PAEDIATRIC CARE Do not leave catheter open - risk of air embolism. CXR to check for a pneumothorax catheter tip at the SVC RA junction but not in RA. Subclavian sterile technique Place supine turn head to contralateral side roll under shoulders to extend neck identify midpoint clavicle. Aim for suprasternal notch pass needle just beneath clavicle at midpoint more medial in older child vein lies anterior to the subclavian artery and is closest at the medial end of the clavicle. Subclavian artery puncture not uncommon cannot compress to stop bleeding but rarely problem unless coagulopathy . Cut down venous cannulation sterile technique Procedure Identify landmarks. PROCEDURES AND EQUIPMENT 163 Brachial Infant - one finger breadth lateral to the medial epicondyle of the humerus. Small child - two finger breadths lateral .
