How (not) to Cannulate in the Antecubital Fossa (ACF)

Working on a pre hospital emergency you can be forgiven certain etiquettes in standard procedures.  Like intubating a patient whilst they’re on a filthy floor in a corner of a darkened room. But, as long as there is no ‘real’ harm done to the patient then it should be fine . . . shouldn’t it?

I opened the roller clamp on the IV Paracetamol and held the bottle above the patient’s head to watch the flow.  But, instead of seeing the drips coming down, I saw the patient’s blood run vertically up the tube toward the bottle!

Ah . . . I thought, this is awkward . . .

Try and aim for the blue bits

Antecubital Fossa (ACF)

I’d arrived first on scene, to find my pt sat against a brick wall nursing a pretty knackered arm.  He’d been assaulted with a metal bar and it currently looked like his arm was broken in several places.

Police were already on scene attempting to calm the environment and keep the general public at bay.

I quickly ascertained that I’d need IV access to give analgesia. And seeing as how the shattered arm was a no go, I set about sorting access in the good arm.

So, whilst the patient chomped away at laughing gas I put the tourniquet on.  It was dark, cold, raining, and there was lots of shouting going on.  But, I was used to this, and feeling the patient’s antecubital fossa (ACF)* area I could tell he had good veins, which meant to me, easy access.  I decided to keep the cannula to a medium size (as all I was going to give was paracetamol and morphine) and went for a 18 gauge green.

Because of the poor light, I had a quick ‘tap tap tappety feel’ of where the vein was and inserted the cannula in one swift movement.  I felt that distinct ‘pop’ of the needle poking through the vein, and saw that I had flash back on the cannula.  With habitual speed I unclipped the tourniquet, raised the patient’s arm and placed pressure on the cannula – to attempt stopping the blood – and removed the needle.

Blood poured out of the cannula signifying I either hadn’t pressed hard enough or wasn’t pressing quite in the correct place.  Still, this happens sometimes, especially in the pre hospital environment and I didn’t pay much attention to it.  And, quickly sealing the end with the bung I set about securing the cannula in place with the appropriate dressing and giving it a quick flush through.

Then, I attached IV paracetamol to the patient’s cannula.  Again I failed to block off the blood properly and my hand ended up covered in the patient’s blood.  Barely thinking twice about this episode I stood up and released the roller clamp on the line and watched in horror, as the patient’s blood ran quickly up the line toward the bottle!

I’d cannulated his artery!  Bollocks!

It all fell in to place.  Lots of blood.  Really warm blood. It going up the tube.  Yep. That’s an artery alright.

Ok, I thought, don’t panic. First up – admit you’ve done wrong.

“Um, I’m really sorry. I’ve stuck the needle in one of your arteries”

Next up, fix it.

I glanced at his shattered arm – can’t use that, don’t know what vascular damage is done there.  And checking everywhere else on his good arm I couldn’t find anything.

Come on! Seriously?! Nothing?  

It quickly dawned on me that if I needed access that bad, I was going to have to retry the original ACF vein.

Oh god!  This could get messy.

So, with several police torches shining my way, I carefully extricated the artery cannula and plugged it with some tightly rolled up gauze.  So far so good. Next, I carefully inserted a cannula in the vein fractionally to artery’s side and secured it in place.  And finally, and thankfully, I was able to administer analgesia and make the patient “comfortable”.

A little later at hospital I admitted my slight ‘faux-pas’ to the Doctor during handover.

The Doctor raised his eyebrows.

“So, you stuck a cannula right next door to where you cannulated the artery?!”
“Um . . . yes”
“Well.  That’s rather audacious isn’t it”

At the end of shift I finalised the job by admitting a Datex report – to make it official – and then proceeded to get a roasting from my team mates.  As you do.

What did I learn from that escapade,  don’t get cocky.  Use a torch.

Binder

*The area in the bend in your arm

 

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4 thoughts on “How (not) to Cannulate in the Antecubital Fossa (ACF)

  1. seems i have done the same yesterday. canulated at right acf all went normally. flushed fine and morphine went in fine. no swelling or difficulty pushing through. later that day got slagged off at hospital accused of canulating the artery

  2. seems i did the same thing yesterday. canulated right acf. all went well and flushed normally. morphine went in normally. no swelling to suggest i missed. got slagged off at hospital later accused of canulating an artery. really pissed off because i still dont believe i did. everything seemed normal

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