I know this is an old thread, and maybe this goes against current teaching, but why not throw in a quick femoral?
If you truly need a line in the ED to save a life, your first choice should be large bore peripherals, anyways Then if you need a central line I never understood the need to always get THE PERFECT CENTRAL LINE.
Sure, there's a higher rate of infection with femorals, but that doesn't happen in the first 24 hours, and the infection rate of IJ/subclavian aren't zero. Secondly, this patient is septic and will be on every antibiotic known to man. Are you worried they're going to get septic, again?
In a crashing and critical patient the last catastrophe you want is a carotid thrombus and stroke, or a dropped lung which might not be picked up right away in a supine patient getting supine cxr's. Granted, the carotid stick in this patient is likely to amount to nothing but if it clots, it's catastrophic, and obvious what/who caused it.
The only real reason not to do a femoral is because the Hospitalist or ICU doc gets irritated that he/she has to place another line later. But so what? In a crash life-saving situation, you get the quickest line you can get. If it's not a crash life-saving situation the it can wait for ICU dude to get his perfect made to order central line later. If your femoral line gets infected, a week later that's his fault for not placing the ideal line, in ideal sterile and controlled icu conditions later once you've stabilized the patient.
If you can put in the perfect central line quickly, the fine, do it. But once you start talking about "oops, did I just cause a carotid perf/CVA or drop a lung?" then I'm immediately saying you made he wrong line choice.
I know they want every line done flawlessly now, with zero infection rate, done with ultrasound guidance and in OR like conditions, but sometimes that doesn't apply to true crash settings in the ED. So, before you do a central line, it's important to ask yourself a couple of questions:
1-Should I be placing another line choice (peripheral or IO) since you can get fluids in quicker with peripherals anyways, and should maximize that before starting pressors, anyways? And if you do decide to place a central line,
2-Am I placing, A- "The Perfect Central Line," or B- A crash life-saving central line?
If "A," the why can't it wait for perfect ICU-guy, with perfect ICU-guy hair, to place it later in perfect ICU conditions?
I don't know. Just some things to ponder.