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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....
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....