On the dorsum of the hand, the most commonly used veins are the tributaries of the cephalic and basilic veins and the dorsal venous arch (Fig. 73.1). The cephalic vein, which is located on the radial border of the forearm just proximal to the thumb, is predictable in its location. It is a large vein that is well secured to the fascia, making it unlikely to move or “roll” during venipuncture or venous cannulation. In the forearm, the cephalic, basilic, and median cubital veins may be difficult to locate in a younger child because of subcutaneous fat. Veins on the volar side of the wrist, if visible, can also be cannulated. It is important to avoid puncturing the radial or ulnar arteries or nerves that lie in close proximity to these vessels. The axillary vein is a continuation of the basilic vein and should be used with caution for peripheral venous cannulation.

The saphenous vein, which is situated about 1 cm above and in front of the medial malleolus, is a good choice for cannulation (Fig. 73.2). It is large and well secured by fascia, which prevents it from rolling when cannulation is attempted. Because of its reliably predictable location, it is one of the few veins appropriate for attempting access by location alone (i.e., a “blind stick”). The median marginal veins and the veins of the dorsal arch of the foot also may be accessed. The anterior and posterior tibial veins form the popliteal vein, which continues

as the femoral vein. The long saphenous vein drains into the femoral vein. When the patient is critically ill and peripheral venipuncture proves impossible, the femoral vein, which is a site for central catheterization, may be used for venipuncture. In the femoral triangle, the anatomic relationship from lateral to medial is nerve, artery, vein, and lymphatic, often expressed by the acronym NAVL. This relationship can be remembered using the mnemonic “NAVL towards the navel.” Therefore, if the clinician can palpate the arterial pulsations, the vein lies immediately medial to the pulsations. The femoral artery lies midway between the anterior superior iliac spine and the pubic symphysis 1 cm below the inguinal ligament. Using this anatomic landmark, the femoral vein can be punctured in cases when the artery is not palpable (e.g., hypotension). Cannulation of the femoral vein, an approach for central venous access, is described in Chapter 19.

Scalp veins are prominent in infants, especially those under 3 months of age. From a practical standpoint, scalp veins may be accessed in patients up to the age of about 9 months if the hair is relatively thin. The scalp veins are closer to the surface and are supported underneath by the bony cranium (Fig. 73.3). They can be used for both venipuncture and venous access. Scalp veins are not generally accessed when airway management is in progress because of space limitations and movement of the head and neck. Scalp arteries and veins should be differentiated by palpation. Arteries are generally more tortuous than veins. Blood flow through the scalp arteries is away from the heart, whereas blood flow through the scalp veins is toward the heart. The clinician can lightly press the vessel with fingers and block the blood flow at two points. Releasing one point and watching the vessel refill will reveal the direction of blood flow. If there is no refill, the procedure is repeated releasing the other pressure point on the vessel. If an artery is cannulated by mistake, fluid instillation will cause immediate blanching in the surrounding area, which will indicate that the catheter should be removed. The temporal veins anterior to the earlobe are the largest and the easiest to locate. The frontal vein down the middle of the forehead is another good choice.

The external jugular vein is usually cannulated by physicians rather than nurses because of its location (Fig. 73.3). Despite its location in the neck and proximity to the central circulation via the subclavian vein, the external jugular vein is a peripheral vein. It is typically used only when cannulation of other peripheral sites is unsuccessful or when considerable time may be saved in managing a critically ill infant or child. As with scalp veins, the external jugular vein can be a problematic site to use during resuscitative efforts because accessing it interferes with airway management. It extends from the lower lobe of the ear to the medial clavicular head across the sternocleidomastoid muscle. Since it cannot be palpated, the external jugular vein must be visualized, which is best accomplished by having the patient in the Trendelenburg position with the head turned away from the site to be punctured.

Verbal consent is usually sufficient before venipuncture or placement of a peripheral intravenous catheter. It is essential to prepare the patient and the parent for the procedure, which they may view as an ordeal. In an emergent situation (e.g., cardiac arrest or a seizing child), the clinician should not take time to explain all details of the procedure. A quick explanation that an intravenous line needs to be started to give medications is adequate. This can be explained by a staff member helping with the care of the patient (5).

When obtaining venous access is not emergent, it is important to discuss the reason for the procedure with the parents and patient in terms they understand. The clinician should explain that there will be a “pinch” when the needle and plastic catheter go into the vein but that the needle will be removed, leaving only the catheter in the vein to give fluids and medications. The child may understand better if told that it is like a straw through which “water and medicine” that will make the child better can be given. Because the pinch hurts, the child should be told that it is okay to cry but that it is important to remain as still as possible. If time allows, explaining with dolls or stuffed animals may also help. This is usually possible for elective procedures done outside the ED and occasionally in the urgent setting. While such measures do not lessen the pain of the procedure, taking time to allay fears will decrease the amount of emotional trauma experienced by the child.