Central Line Question...

[MediCane2006]

So I'm confused....

Got called down to the ED for a ruptured AAA (prior endovascular repair) last week. Guy was in extremis, tachycardic, hypotensive, with NSS getting dribbled in through a 20G in his hand. While my R3 was on the phone with the vascular attending, I grabbed a Cordis kit and placed a L subclavian Cordis in about ten seconds....easy stick, no resistance. Bilateral breath sounds after the line was placed, no change in sats.

The intern and I were squeezing blood in through the Cordis as fast as we could, until the ED attending came running over and yelled at us not to use the line until we "confirmed position" with a chest X-ray. I ignored him, because at this point I figured we were essentially running a trauma code and there was no way we were getting blood in through the one pathetic peripheral that the guy had.

The patient ended up dying before we could make it up to the OR. The ER attending came up to us afterwards and was saying that we should have placed a femoral line, which could have been used right away. My rationale was that A. a femoral approach would have risked snagging the graft if I'd accidentally stuck arterial and B. a subclavian line gives you access above the diaphragm. Plus I figured that if it was a venous stick, with good bilateral breath sounds, we could use the line for resuscitation and be fairly confident it was in place (obviously confirming position with chest x-ray if the patient stabilized).

Or is a femoral line the way to go in a case like this? Just wanted to get the input of residents who have done this kind of thing before....

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[SLUser11]

So I'm confused....

Got called down to the ED for a ruptured AAA (prior endovascular repair) last week. Guy was in extremis, tachycardic, hypotensive, with NSS getting dribbled in through a 20G in his hand. While my R3 was on the phone with the vascular attending, I grabbed a Cordis kit and placed a L subclavian Cordis in about ten seconds....easy stick, no resistance. Bilateral breath sounds after the line was placed, no change in sats.

The intern and I were squeezing blood in through the Cordis as fast as we could, until the ED attending came running over and yelled at us not to use the line until we "confirmed position" with a chest X-ray. I ignored him, because at this point I figured we were essentially running a trauma code and there was no way we were getting blood in through the one pathetic peripheral that the guy had.

The patient ended up dying before we could make it up to the OR. The ER attending came up to us afterwards and was saying that we should have placed a femoral line, which could have been used right away. My rationale was that A. a femoral approach would have risked snagging the graft if I'd accidentally stuck arterial and B. a subclavian line gives you access above the diaphragm. Plus I figured that if it was a venous stick, with good bilateral breath sounds, we could use the line for resuscitation and be fairly confident it was in place (obviously confirming position with chest x-ray if the patient stabilized).

Or is a femoral line the way to go in a case like this? Just wanted to get the input of residents who have done this kind of thing before....

Did you put the subclavian in for all those reasons, or did you think of them after the fact when contemplating what the ER doc said? I guess what you have to ask yourself is: did you put it there because that is what was best for the patient, or because it's what you're used to doing?

I think most surgical residents would agree that we put in infinitely more subclavians than femorals, and they seem more automatic.


I've argued with other residents on SDN about this, but in almost any emergency situation, esp. trauma and codes, a femoral line is quicker and safer. I can try to find the thread if we want to have an in depth discussion.

The big question is: what if you had given the crashing patient a tension PTX? Then what? Can the patient survive your complication?

 

[MediCane2006]

That's a good point - we definitely put in subclavians as the vast majority of our elective lines. But at least at my program, when we respond to codes we're usually responsible for getting access - which in a coding patient getting cpr/intubated, means a femoral line....so I'd have to say I've probably put in about equal numbers of both subclavian and femorals. And no question, a femoral is a much easier line for me - I can and have put them in left-handed, from across the bed, on a patient that's bouncing up and down getting CPR.

In this patient, I honestly wasn't sure where the best place for a line was...my initial instinct was to go femoral, but then I just started picturing a stat ex-lap or thoracotomy with an attempted aortic cross-clamp and figured it would be better to have the line above the diaphragm. You're right, if I'd dropped the lung, it probably would have been (even more) catastrophic but at this point the patient was pretty much dying in front of us, so I just went for the SC.

I guess my question is, under what circumstances in an emergency like this one is a subclavian approach preferred over a femoral? (comfort level with the two being similar)?

 

[maxheadroom]

My question is why did you have to put a line in? You would think that the ED physician would have seen the need for better access than he had and . . . you know . . . done something.

Back in the day when I did that kind of thing, I would have probably checked "None of the above" and gone with an IJ. While you can drop a lung with an IJ, I've never seen it done. I've only had one patient that I couldn't get into the IJ on and that was one who was hypotensive and I was being super cautious about hitting the carotid.

I just hate femoral lines. I hate the groin. But it's always a good option in a pinch.

 

[MediCane2006]

My question is why did you have to put a line in? You would think that the ED physician would have seen the need for better access than he had and . . . you know . . . done something.
.

Well, that's a great question and one that I posed to the ED resident when we were chatting afterwards. He let this guy go to CT unmonitored, with a 20G IV in his hand.

The ED at this particular hospital is horrendous. Seriously, I fight with these guys on a daily basis. They inspire diatribes that I would have otherwise never known I had in me....

....and yeah, I need to get more comfortable with the IJ. Our program requires that we use a SiteRight (portable ultrasound) for elective IJ's, so I've never really gotten comfortable with a blind stick in the neck. Would have probably been my last choice in this situation, but I can see how it would be a good skill to have in your arsenal.

 

[maxheadroom]

I did a ton of IJs as an intern on anesthesia. They never used U/S and I never saw them have a problem. It was a great experience for me. Show up every morning. Put in a radial art line while they were giving some happy drugs, intubate, place an IJ, and then float a Swan. Move on to Room 2 and repeat. It was a great month for pure procedural stuff like that. I had that as my second month of intern year, so I was more comfortable with an IJ than I was with SC. I kept freaking out the surgery attendings by putting in a neck line instead of a SC, but they got used to it.

It's a good line to know -- there are times when SC isn't available and the groin isn't a good option.

 

[Celiac Plexus]

So I'm confused....

Got called down to the ED for a ruptured AAA (prior endovascular repair) last week. Guy was in extremis, tachycardic, hypotensive, with NSS getting dribbled in through a 20G in his hand. While my R3 was on the phone with the vascular attending, I grabbed a Cordis kit and placed a L subclavian Cordis in about ten seconds....easy stick, no resistance. Bilateral breath sounds after the line was placed, no change in sats.

The intern and I were squeezing blood in through the Cordis as fast as we could, until the ED attending came running over and yelled at us not to use the line until we "confirmed position" with a chest X-ray. I ignored him, because at this point I figured we were essentially running a trauma code and there was no way we were getting blood in through the one pathetic peripheral that the guy had.

The patient ended up dying before we could make it up to the OR. The ER attending came up to us afterwards and was saying that we should have placed a femoral line, which could have been used right away. My rationale was that A. a femoral approach would have risked snagging the graft if I'd accidentally stuck arterial and B. a subclavian line gives you access above the diaphragm. Plus I figured that if it was a venous stick, with good bilateral breath sounds, we could use the line for resuscitation and be fairly confident it was in place (obviously confirming position with chest x-ray if the patient stabilized).

Or is a femoral line the way to go in a case like this? Just wanted to get the input of residents who have done this kind of thing before....

Generally a femoral cordis is the way to go in a code like the one you're describing. It's safe, it's quick, and it keeps you out of the way of the folks who are managing the airway, or putting in a chest tube, doing a thoracotomy, etc... And it does not require a cxr to make sure you didn't cause a ptx.

It should be noted though that femoral lines have serious complications as well... retroperitoneal hematoma, inadvertent arterial cannulation (easy mistake in a profoundly hypotensive patient in an emergent situation).

As far as ED attendings questioning you goes... it can be irritating but they have an obligation (as well as any member of your team) to question any move you make during a resuscitation. There is no place for yelling/disrespectful behavior though, and often times this type of behavior only endangers the patient. However, getting questioned sometimes saves you from a bad move, or prevents you from making one in the future. In the case that you are describing though, it doesn't sound like it mattered much since the patient died from a ruptured aaa.

 

[Castro Viejo]

Or is a femoral line the way to go in a case like this? Just wanted to get the input of residents who have done this kind of thing before....

No evidence based medicine to back this up, but I've always been taught to use subclavian or internal jugular lines for resuscitation in patients who were hypotensive and not undergoing some upper body intervention (i.e., intubation, thoracotomy, chest compression/CPR, etc.). The rationale is a hypotensive patient may or may not have a palpable femoral pulse and it's just a shot in the dark. Anatomical landmarks for groin placement aren't as reliable as the landmarks used for subclavian or internal jugular placement.

I personally agree with plastics man and would've gone with an IJ myself.

 

[surgical06]

i had a similar call as you with kinda the same results.

from the monday morning quarterback. that guy shouldn't have been in the ER for more that 5minutes, if that. ruptured AAA need to go straight to the OR. lines ect can be put in on the table by anesthesia, usually an IJ. volume resus wasn't going to do it for him. my guy had a belly 3x normal , needed urgent or. transfusion can worsen hemorrhage. learning points

1) always go quickly to OR, agressive resuc can be done in or after you have opened
2) NEVER NEVER NEVER, intubate a ruptured AAA unless u r ready to make your incision at that time. anesthesia will want to intubate for low bp, don't let em... i did..damm. bag, atropine and roll out.

the line is trivial, in codes u get the access you need, IJ's and subclavians can both cause ptx.

 

[opr8n]

the key for me is that the guy is hypotensive and not coding (ie needing cpr)
so its not like a code IMO
I think any of the three is ok
and since IJ/SCL would get the fluyid to the heart faster, I think that is plausible

Plus as someone mentioned earlier
ina hypotensive patient, who you may have in T-burg
the femoral vein can be very hard to stick even ina thin person

 

[Winged Scapula]

Enough of this EBM stuff...you get the line you can get.

If its femoral, fine...if its SC fine, even an IJ (if you can get to it with all the people running around the patient's head).

 

[Castro Viejo]

Enough of this EBM stuff...you get the line you can get.

Word up. Thanks for bringing us back to reality.

For a minute there I thought this had turned into an Internal Medicine forum. We'd all sit around, debate about the relative merits of each site for the CVL, and the patient would just die in front of us.

The bottomline is you got access, it worked, and you tried your damndest to resuscitate him.

Although, how much is too much resuscitation? How much "hypotension" could be tolerated by this guy without raising his BP too high and "knocking off the clot" around his ruptured AAA?

And, if you really wanted to be a cowboy, you theorectically could've cracked this guy's chest and cross-clamped the aorta.

 

[MediCane2006]

And, if you really wanted to be a cowboy, you theorectically could've cracked this guy's chest and cross-clamped the aorta.

Well, that's what I kinda wanted to do when he coded. But by that time my R3 was down there, and nixed the idea. You don't know this ER....we would have had to crack the chest with a suture removal kit, because good luck finding a thoracotomy tray....

 

[Castro Viejo]

Then forget about cracking the chest. Lap the belly and squeeze the aorta.

Either way you'll have a good time.

 

[Castro Viejo]

Oh, but don't let the small bowel spill over. That's no good for nobody.

 

[SocialistMD]

I wouldn't listen to the criticism of the person who put you in the limited-access situation you faced; the patient was stable enough for you to put in your line of choice and that is what you did. If you dropped the lung, it isn't like the patient would be alone; you could needle him and then put in a chest tube; problem solved.

 

[surgical06]

"You don't know this ER....we would have had to crack the chest with a suture removal kit, because good luck finding a thoracotomy tray....

classic, hillarious.....lololololololol.. made my day.

 

[MediCane2006]

classic, hillarious.....lololololololol.. made my day.

But true!!...as sad as that is. I've been a little tempted to hide a thoracotomy tray in the call room or somewere close to the ER just in case the need should arise.

 

[opr8n]

let us not forget
we are solution oriented people
if a patient is hypotensive and needs fluids/blood
you get the access you can get
dont sit around for an hour debating
well if we had done this then . .
or if we had done this, then . . .
if you do nothing for the paitient ina timely fashion
you have done them NO favors

 

[SLUser11]

let us not forget
we are solution oriented people
if a patient is hypotensive and needs fluids/blood
you get the access you can get
dont sit around for an hour debating
well if we had done this then . .
or if we had done this, then . . .
if you do nothing for the paitient ina timely fashion
you have done them NO favors

Actually, we debate these things now, in a controlled setting, so when we are faced with an unstable patient in a high stress environment, our response is both automatic and correct, instead of taking a "whatever works" approach to the situation.

 

[Castro Viejo]

Suppose your subclavian had gone up into the head? You're squeezing blood in. Any significant risk there?

I don't think so. Now, floating a Swan up the jugular and somwhere into the brain? I've done that. I dunno if I did anything bad though.

 

[maxheadroom]

I've done it at least once. I also know of a patient who had an IJ put in the carotid during a code. Once the patient was resuscitated, there was a realization that the line was arterial. No major problem, but people were a bit distressed for a while.

 

[Castro Viejo]

I've done it at least once. I also know of a patient who had an IJ put in the carotid during a code. Once the patient was resuscitated, there was a realization that the line was arterial. No major problem, but people were a bit distressed for a while.

One of my R2s put an art line into the carotid.

"I couldn't get it into the radial!"

She used the same line a few months back when she put an art line into the ulnar artery.

 

[NJA61479]

Bottom line is that 2- 18 guage peripheral IV's can deliver 2L fluid via a Level I infusion pump in less than a few minutes. Don't fixate on what kind of central line and where it should be placed. In an emergency all you need is a temporary line which could be placed at any access site but preferrably in the OR. There is only one thing that could have saved this patient, bright lights and cold steel.

I would have opted for the thoracotomy with cross-clamp although that would be an interesting one to present at M&M's

 

[MediCane2006]

Trust me, I REALLY wanted to do the thoracotomy. But the guy was at least 87...and not a good 87. I just...couldn't.

 

[LovelyRita]

I put in a subclavian in the ER for a ruptured AAA. Was going to get a CXR but the vascular fellow's like: "did it go right in?" I said, "yep." He's like, it's fine then, let's get up to the OR. While I was doing that 2 paramedics were getting peripheral access as well. He had b/l breath sounds after the line. He made it, too.

Like someone above said, you have someone circling the drain, do what you can, when you can, time allowing. At least you're doing something. However I'm sure there's some malpractice lawyers out there who feast on this stuff. Or try to, anyway.

 

[debvz]

Go with what you're comfortable with. During traumas, I can usually get a subclavian cordis in quicker than the ED resident can get into the femoral.

I'm a little leery of ED resident-placed trauma lines, anyway. I had a patient not too long ago with hypotension refractory to 4 units of prbc's -- on laparotomy, those 4 units were in the abdomen with an intraperitoneally placed femoral line, courtesy of the ED resident. So, even femorals can have their complications.

And don't even get me started on their chest tubes - that'd be another thread in itself...

 

[jetproppilot]

So I'm confused....

Got called down to the ED for a ruptured AAA (prior endovascular repair) last week. Guy was in extremis, tachycardic, hypotensive, with NSS getting dribbled in through a 20G in his hand. While my R3 was on the phone with the vascular attending, I grabbed a Cordis kit and placed a L subclavian Cordis in about ten seconds....easy stick, no resistance. Bilateral breath sounds after the line was placed, no change in sats.

The intern and I were squeezing blood in through the Cordis as fast as we could, until the ED attending came running over and yelled at us not to use the line until we "confirmed position" with a chest X-ray. I ignored him, because at this point I figured we were essentially running a trauma code and there was no way we were getting blood in through the one pathetic peripheral that the guy had.

The patient ended up dying before we could make it up to the OR. The ER attending came up to us afterwards and was saying that we should have placed a femoral line, which could have been used right away. My rationale was that A. a femoral approach would have risked snagging the graft if I'd accidentally stuck arterial and B. a subclavian line gives you access above the diaphragm. Plus I figured that if it was a venous stick, with good bilateral breath sounds, we could use the line for resuscitation and be fairly confident it was in place (obviously confirming position with chest x-ray if the patient stabilized).

Or is a femoral line the way to go in a case like this? Just wanted to get the input of residents who have done this kind of thing before....

Every day in every operating room in america anesthesiologists put in IJs and subclavians, then subsequently use them for the case.

CXR for placement is done at the end of the case.

I don't agree with the ER guy.

I havent done a single femoral line in eleven years of private practice.

I've done what you describe you did hundreds and hundreds of times.

He should've complimented you on your deftness, not scolded you.

 

[opr8n]

Go with what you're comfortable with. During traumas, I can usually get a subclavian cordis in quicker than the ED resident can get into the femoral.

I'm a little leery of ED resident-placed trauma lines, anyway. I had a patient not too long ago with hypotension refractory to 4 units of prbc's -- on laparotomy, those 4 units were in the abdomen with an intraperitoneally placed femoral line, courtesy of the ED resident. So, even femorals can have their complications.

And don't even get me started on their chest tubes - that'd be another thread in itself...

ive seen ER resident chest tubes through and through lung parenchyma
and subclavian lines IN THE CHEST (no wonder the dopamine wasent working)

 

[supercut]

Every day in every operating room in america anesthesiologists put in IJs and subclavians, then subsequently use them for the case.

CXR for placement is done at the end of the case.

I don't agree with the ER guy.

I havent done a single femoral line in eleven years of private practice.

I've done what you describe you did hundreds and hundreds of times.

He should've complimented you on your deftness, not scolded you.

.....Maybe he was jealous!