At our institution my attendings always want to place a large 9fr or 12fr CVC in all penetrating traumas, even if we have good large bore IVs.
Curious what others do?
Curious what others do?
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yea , if you stab your hand, why would i be putting in a MAC line??
Im guessing they want central lines for pressors.. if its just fluid and clearly you are able to get good access, probably put in a RICC line if you need more than a 14G. A central line, with the prep, draping, etc takes so much longer than peripheral access..
Im guessing they want central lines for pressors.. if its just fluid and clearly you are able to get good access, probably put in a RICC line if you need more than a 14G. A central line, with the prep, draping, etc takes so much longer than peripheral access..
I’d say we typically place a CVC but not always. The main issue in penetrating trauma is to get the case started ASAP and a central line should not delay the case. Sometimes that means placing a line under the drapes. If for some reason that’s not feasible we will rely on large bore IVs (16g or bigger) or a RIC line. With a RIC and a Belmont, you should be good to go.
Yes I’m aware of this and that’s why sometimes I don’t feel like the CVC is needed. A RIC is about the fastest flow rates you can get.
A few important considerations IMO
- Access that is big enough that the catheter isn't the rate limiting step (usually it's product availability)
- access that won't dislodge or infiltrate under pressure
- access that is appropriate for post-op care (pressors/reliability), assuming you get there
- access that won't delay the surgery start
A quick EJ after intubation takes very little time. Indeed, I've done it when the gnats are buzzing about the pelvis XR or some nonsense. It's the best time for full supine or even a bit of T-burg positioning when no one notices or complains.
(assuming y'all are intubating with the collar off...and assuming anesthesiologists are intubating in the ED; I assume the same could be done in the OR...in my admittedly limited trauma OR experience, patients are usually flat/supine [jack up the PEEP a bit to help])
I am not ever "reaching under the drape" (not an anesthesiologist), but I suspect a "peripheral IJ" wouldn't draw much attention either. Clipboard nurses have no idea how to chart it -- and therefore never scream about CLABSI when a patient is trying to hemorrhage to death.
Both, but especially the "peripheral IJ", are easily upgraded with a RIC. And, as long as you connect the primary "trauma" tubing to the RIC directly and use the first port off the resus line for pressors, this becomes the ideal (IMnHO) resuscitation line.
That said, my current hospitals don't have RICs and I seem to be one of the few docs who understands the beauty of "short and fat". When I am involved in the initial resus (becoming rare these days), the cordis or MAC is always placed (but it's a big show involving people who just don't know).
HH
(assuming y'all are intubating with the collar off...and assuming anesthesiologists are intubating in the ED; I assume the same could be done in the OR...in my admittedly limited trauma OR experience, patients are usually flat/supine [jack up the PEEP a bit to help])
I am not ever "reaching under the drape" (not an anesthesiologist), but I suspect a "peripheral IJ" wouldn't draw much attention either. Clipboard nurses have no idea how to chart it -- and therefore never scream about CLABSI when a patient is trying to hemorrhage to death.
Both, but especially the "peripheral IJ", are easily upgraded with a RIC. And, as long as you connect the primary "trauma" tubing to the RIC directly and use the first port off the resus line for pressors, this becomes the ideal (IMnHO) resuscitation line.
That said, my current hospitals don't have RICs and I seem to be one of the few docs who understands the beauty of "short and fat". When I am involved in the initial resus (becoming rare these days), the cordis or MAC is always placed (but it's a big show involving people who just don't know).
HH
If the hemorrhage is massive , i always drop at least a 9F central. Ive seen RIC catheters infiltrate, I've never seen a 9F infiltrate, and 100% reliability is necessary for these cases in my opinion. If you aren't using MAC catheters then you can put a SLC through the hemostasis valve and then you also have at least one extra access site that is also 100% reliable for things like pressors, metabolic management, and drug incompatibilities.
You can get that sucker in and running really fast if you aren't concerned with sterility, which you shouldn't be in a situation like that.
Just take it out once new sterile access is secured later if the patient survives the OR.
It also lets you monitor CVP, which I think is mandatory if you're using a rapid infuser and you don't know the patient's cardiovascular history. In patients with significant RV and tricuspid disease, running the rapid infuser at maximum volume can overwhelm a bad RV and cause hypotension itself. Check out the university of utah rescue TEE series for some pictures.
I put a LOT of central lines in under duress though so I'm comfortable with it. We are a high volume vascular and cardiothoracic center
You can get that sucker in and running really fast if you aren't concerned with sterility, which you shouldn't be in a situation like that.
Just take it out once new sterile access is secured later if the patient survives the OR.
It also lets you monitor CVP, which I think is mandatory if you're using a rapid infuser and you don't know the patient's cardiovascular history. In patients with significant RV and tricuspid disease, running the rapid infuser at maximum volume can overwhelm a bad RV and cause hypotension itself. Check out the university of utah rescue TEE series for some pictures.
I put a LOT of central lines in under duress though so I'm comfortable with it. We are a high volume vascular and cardiothoracic center
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We're Level 1 Trauma.
As others have suggested, we (generally speaking) do what the case dictates and allows, but do not have a policy as to what must be placed. Even in horrific trauma, as long as the peripherals have very good flow, we'll use those until "source control"; our surgeons are very good, and will often to the site of hemorrhage, stop bleeding, and then ask us if we need some time to place lines or "catch up". For true exsanguinating hemorrhage, this is often more effective that delaying surgical intervention to try to pick a vascular access device that we think will allow us to keep up with the bleeding.
For RICs, I've noted a couple of times that they have seemed to blow proximally - a RIC placed in a large AC vein seemed to have caused blown vessels in the shoulder/clavicle region when placed under pressure with the Belmont. I rarely use them.
Adherence to "the only right way" is probably the biggest folly; we had a junior faculty who refused to place anything other than 16 or 14g PIVs - I remember racing into a room to help, while she was saying "We never needed at central line at Famous Trauma Center where I trained, and we did these cases all the time" as she objected to my recommendation to place a Cordis when the Belmont was alarming, blood wasn't flowing, and the pressures were sh*tty. I was like "Hey - I'm not the one who overheaded for Anesthesia STAT help."
As others have suggested, we (generally speaking) do what the case dictates and allows, but do not have a policy as to what must be placed. Even in horrific trauma, as long as the peripherals have very good flow, we'll use those until "source control"; our surgeons are very good, and will often to the site of hemorrhage, stop bleeding, and then ask us if we need some time to place lines or "catch up". For true exsanguinating hemorrhage, this is often more effective that delaying surgical intervention to try to pick a vascular access device that we think will allow us to keep up with the bleeding.
For RICs, I've noted a couple of times that they have seemed to blow proximally - a RIC placed in a large AC vein seemed to have caused blown vessels in the shoulder/clavicle region when placed under pressure with the Belmont. I rarely use them.
Adherence to "the only right way" is probably the biggest folly; we had a junior faculty who refused to place anything other than 16 or 14g PIVs - I remember racing into a room to help, while she was saying "We never needed at central line at Famous Trauma Center where I trained, and we did these cases all the time" as she objected to my recommendation to place a Cordis when the Belmont was alarming, blood wasn't flowing, and the pressures were sh*tty. I was like "Hey - I'm not the one who overheaded for Anesthesia STAT help."
Obviously it’s true that source control is more important than anything else. But central lines can be placed while the surgeon starts to cut. Draping can almost always be modified so you can have access to a central vein somewhere while they cut down. In a ruptured aneurysm for example, you can probably beat the surgeon to completed central access before they get access and the occlusion balloon inflated. It’s very helpful to have at least one extra pair of experienced hands on both sides of the drapes for major time sensitive cases or at least have some advanced notice so you can set everything up and be ready to go
what? why would CVP be mandatory? CVP is not accurate in open chest or stuff like that. It's definitely also not accurate if you are rapidly infusing thru it. You often see hypotension with rapid infusion even without RV dysfunction/tricuspid disease. Unclear of etiology but there are papers on it.
I have seen RIC infiltrate but very rarely. It's good that many places have Belmont these days that tells you the infusion pressure. I have never heard of 9F infiltrate but ive definitely heard of lots of bad complications during placement like arterial dilation, or SVC rupture
I try not to place RIC in AC if possible since the vein curves there. It's almost always lower arm where its easily monitored, or upper arm with ultrasound.
it wasn't a trauma case but it was a large case. case got cancelled or should i say changed to svc repair. patient probably had a weak svc since the anesthesiologist has done many IJ lines before
If you read what i wrote more closely - I said CVP monitoring is mandatory WHEN YOU DON'T KNOW THE PATIENT'S CARDIOVASCULAR HISTORY because very high volume flow can overwhelm a bad right heart. What you are looking for is an acute rise in CVP and acute TR waves. I never said CVP was an accurate measure of volume status, which is what i assume you are referring to. The waveform and pressures also hold a good deal of diagnostic information in them if you know how to read them. I have never seen a rapid infuser cause hypotension that wasn't attributable to a bad right heart.
Also you can't destroy someone's SVC without doing SOMETHING wrong during placement. I doubt the patient had a "weak" SVC unless there was obvious pathology there. Something that isn't taught well in residency in my opinion is that ALL VEINS are fairly weak walled structures. That's why you have to have great discipline to not do anything against resistance.
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I like where your head's at, and that zimmerman rapid infuser echo shot is bonkers, but honestly by the time your CVP is 30 and you're seeing V waves the pt is probably already dead. Would just drop a probe from the getgo if I had doubts about the LV or RV function (sternotomy scar, abnormal FATE exam in ED, known bad COPDer etc) and that'll allow you start inotropes or slow your infusion rate before you've put the pt into full blown right heart failure.
but if you have a belmont going at several hundred ml/min your CVP will already likely be >30 just from infusion pressure. i honestly never really looked at each individual wave while rapidly infusing. just wasn't on the top of my list of things to do. dont they get blunted from the infusion pressure to begin with
If you’re monitoring the right atrium (not high in the cava near the pressure head) then no the CVP will stay very close to baseline even during rapid infusion with a normal right heart.
You see this effect kind of frequently in cardiac when using the ultimate rapid Infuser , the aortic or venous cannulae on a CPB machine, to pour volume in after separation. A weak right heart gets overwhelmed and we need to pause the volume for a minute before dumping the rest of the pump salvage.
And I agree a TEE is a great idea for major trauma or hemorrhage. But a CVP will clue you in when you are multitasking and need to glance st something quickly .
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I figured briefly pausing the infuser to monitor the CVP was assumed by everyone. The CVP always goes up for me when I'm dumping in volume or giving a fast push through the line. If I'm looking at CVP I like to do it preferentially when nothing is running through the line and the pt is flat.
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Why is anyone checking CVP to begin with in a trauma?
Because the base deficit isn't back yet.
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I think you got got.
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Glad you guys get melol that’s what I get for being post call
last one i got from the ED came up with a 22G IV. And the patient was in the ED for 2 hours
Femoral triple lumen could be okay but femoral Aline????
Please don't make this into an ED bashing thread...especially when this is a thread about which there is not a clearly correct answer, when some anesthesiologists are depending on the CVP during acute resuscitation in this thread, and at the time of this post there is a thread nearby in this forum that shows anesthesiologists having almost no idea how to handle Afib RVR (with a bit of dyspnea/hypoxia and AMS), which is bread and butter EM.
Additionally, this distracts from the potentially educational discussion.
HH
Additionally, this distracts from the potentially educational discussion.
HH
Go back and read the thread. No one is talking about using CVP as a pure marker of volume status and adequacy of resuscitation, but rather an indicator of impending right heart failure and development of severe TR when the Belmont is running at 1000 cc/min.
I agree that most of the time finger pointing is counter productive, but lemme say that as someone who's been involved in cardiac anesthesia and critical care at 3 different institutions, all of which have EDs that have sent up ruptured aneurysms or aortic dissections with at best an 18g PIV, max esmolol and cardene, and no a-line, I don't think any ED bashing in this regard is too far disconnected from reality.
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Please feel free to go to the AF RVR forum and let us know how to treat it ya genius!
Yea it's not to bash. But I don't honestly think the thread shows anesthesiologists don't know how to treat af rvr but more of a discussion about a case that had it.
I would consider such a transfer meeting, if not exceeding, the standard of care for an aortic dissection in emergency medicine.
I honestly wonder what else you would want. Do you want a cordis, ETT, and aline? Do you think you would have all this completed if you were in the ED and had at least five other patients and likely one other critical one? Do you think the ED and hospital administration (outside of academic centers) would tolerate this?
I honestly think that the diagnosis and initial treatment described above is excellent for aortic dissection. I would be thrilled if I was called to the ED and this was already in place.
So, yes, I feel this "ED bashing in this regard is ... far disconnected from reality." And I feel that this "bashing" adds nothing to the discussion in this thread. It seems others disagree. I guess I will keep considering why I am not seeing it similarly.
HH
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This was never a ED bashing thread. your initiative to prevent it by making attacks to other anesthesiologists turned your initial worry a self-fulfilling prophecy. If you want to win influence over others, attacking them sarcastically is not a good way to go. That's my free lesson to you (you probably have been taught this lesson many times, but refused to learn). Or may be your intent was never to win anyone over, but want to show off how awesome you are in an anonymous internet forum and your strategy is to deter others from bashing you by bashing them in the first place.
Furthermore, your understanding of the other patient described in the other thread is also subpar - as many in the thread has pointed out, the a fib w/ RVR may not be the primary event, but instead, a symptom. You should not treat to mask a symptom, you should diagnose then treat.
If this was an emergency AAA, awake a line, Ett, and cordis should take 10-20 mins in the OR (for all 3). the surgeons can cut right after ETT which would easily cut the time before surgery to 10 mins after hitting the OR. If you can't spare 10-20 mins to setup your dying patient in the ED (or you can't do it that fast because you, well, just isn't that good at doing this stuff and can't do it that fast), then send them up to the OR with nothing. But the issue here isn't that the patient presents to the OR with no access, but they show up to the OR with no access after sitting in the "resuscitation bay" for a ridiculous amount of time.
My experience in real life is very similar to the quote above. ED doctors are excellent at recognizing the AAA on a CT with the radiologists' help. The ED doc think they're saving the patients life by getting a central line before they send them to the OR, but instead burns 30 mins to an hour just trying to fumble around to get a central line or a ett. This isn't the care i'd want for my loved ones if they had a ruptured AAA. In my mind, it's a very valid criticism. In others, it's bashing because they take the criticism too personally.
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My criticism is that an exsanguinating patient needs to have a cross clamp aplplied, delaying for anything else is the wrong move.
Additionally , when someone is going to have a surgery, choice of access type and site is critical. For a ruptured aorta, a triple lumen may as well be a neonatal IV, and a femoral arterial line will be a flatline when the occlusion balloon is inflated or the aorta is cross clamped.
Sorry if it sounded like pointless bashing. But unless you’re going to start reading about surgical procedures in enough detail to plan access sites and types (which is fine, you have plenty of other stuff to worry about) then just let us have them ASAP.
Additionally , when someone is going to have a surgery, choice of access type and site is critical. For a ruptured aorta, a triple lumen may as well be a neonatal IV, and a femoral arterial line will be a flatline when the occlusion balloon is inflated or the aorta is cross clamped.
Sorry if it sounded like pointless bashing. But unless you’re going to start reading about surgical procedures in enough detail to plan access sites and types (which is fine, you have plenty of other stuff to worry about) then just let us have them ASAP.
You really expect a cordis to be placed by the ER physician? Man that would be fantastic but sorry to say that is just not the reality. I also disagree with the notion that the lack of a line, cordis, intubation , starting anesthesia and vasoactives while you’re at it.... is considered substandard care.
ER docs are chronically under staffed and over worked. It’s not right, but it’s reality. Sorry but you cannot drop an entire ED to focus on one patient the whole time. If you think you can you haven’t worked in an ER. Assuming it doesn’t take 2 hours for a surgeon to see the patient, these things could easily be done by the surgical team or anesthesiologist. It’s really easy for us to criticize the ER (trust me I’m guilty of it too) but you should put yourselves in their shoes. No they don’t put in 50 plus introducers in their training like we do, so why would you expect them to?
Do you have a lot issues with them wasting time fumbling with access? I’ve found the exact opposite - peripheral IVs are in and maybe arterial line of especially unstable or there is a long anticipated surgical delay. Otherwise I haven’t had too many issues at the various hospitals I have worked at
I could not have said this better.
I honestly feel (not being antagonistic here) that the comments come from having no idea what it is like to run a high-acuity, high-volume ED seeing 2+ patients per hour and being limited by consultants, nursing, supplies.
HH
So what you’re saying is that an undifferentiated patient showed up to the ER in a sea of patients in the waiting room by private vehicle or EMS, was appropriately triaged rapidly and identified as having a lifethreatening insult, had the appropriate diagnostic test ordered, performed and interpreted for a rare, life-threatening disease, paged the appropriate consultant rapidly, waited for a return call, discussed the consult with the appropriate surgical subspecialist, documented a billable critical care note, discussed findings with the patient, requested a post-op bed all while he or she had 10 other patients who need H&Ps, orders, notes written, updating patients/families, procedures and dispositions/consults, while the nurse got two IVs, sent blood, took care of 3-5 other patients, called report, walked the patient to the OR and returned to find a new undifferentiated patient in his or her room?
Wow, they must suck.
I dont really expect any of my patients to come with a cordis unless the patient is massively bleeding.
I agree many EDs are chaotic places and short staffed and you have multiple patients to focus on. However that doesn't mean the best care is being delivered or anywhere close to it. It only means perhaps the best care under those circumstances. If your department isnt adequately supplying your ED with enough workforce, then that's unfortunate but also the reality at many EDs. In the end when you say things like i'm providing poor care for this patient because i have other patients and im overwhelmed is unfortunately just an excuse. not calling out ED docs, it's probably more of a department/system/healthcare failure than anything.
I think we've probably all rotated thru ED at some point in our career as anesthesiologists. I've seen how hectic it can be, and i've seen plenty of things fall thru the cracks. i get it and i dont really give ED people much problems. I've had countless people come up to the OR from the ED with infiltrated/nonfunctioning IVs, but hey if it's not a super stat case I dont really care and just put in a new one, no big deal. the things that do bother the most often are patients who clearly need decent access (either bleeding or at risk high risk) come to me with 22G IVs. Like not expecting a 14 or cordis, just put a 18g IV!
Actually not at all. The patient was a known patient with leaking AAA, transferred from outside hospital to get operated at our hospital. The patient was actually in the ED for more than 2 hours. the anesthesiology team was informed by the surgeon that this patient is coming from outside hospital to get open AAA repair. 2+ hours later neither us nor surgeon received any new info from outside hospital about this patient so we thought the patient died or something. then the surgeon decided to go to the ED to take a look just in case, and found this patient sitting in a corner bed with 22G IV with no monitors on, just sitting there. No one was informed by the ED the patient had been there.
So no in this scenario the ED did nothing, made zero consults, got no scans, did no interpretations, and probably didnt triage correctly either. In reality all the ED had to do in this case was page the surgery team as soon as patient arrived.