Physical Exam Key Points

1. Vital signs. Hypotension or weak peripheral pulses often cause peripheral veins to collapse. Cold ambient temperature may impede access.

2. Extremities. Initially look for an antecubital vein in the upper arm or a saphenous vein located anterior to the medial malle-olus of the ankle if child is clinically stable.

B. Laboratory Data. These studies usually are not helpful in solving IV access problems. Consider obtaining hematocrit and platelet count, because even small amounts of blood loss can be significant in a child.

C. Radiographic and Other Studies. Follow-up chest films should be obtained after central lines are inserted to confirm their locations.

V. Plan. IV access should be approached in the following order in both emergent and elective situations.

A. Peripheral (Arm). Start distally and work proximally. Lower extremities can be used for infants, toddlers, or children who are nonambulatory due to underlying disease (eg, cerebral palsy). Scalp veins can be used in patients up to 18 months of age. Standard-gauge catheters for children are 24, 22, 20, and 18 gauges, depending on age of child and clinical setting. For elective IV line, application of warm towels or a heating pad on the extremity for a few minutes may dilate the vein.

B. External Jugular. Simple IV catheters can be placed in the external jugular vein without difficulty and with little or no risk to child. Place child in Trendelenburg (head-down) position and gently occlude vein just above the clavicle to dilate it.

C. Intraosseous. Attempt if child is in cardiopulmonary arrest or being treated for decompensated shock with no venous access.

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