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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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?
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?
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
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.
SVC rupture!?!?! WTH????
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.
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.
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
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
Adherence to "the only right way" is probably the biggest folly
Why is anyone checking CVP to begin with in a trauma?
Because the base deficit isn't back yet.
I think you got got.To each his own. I always resuscitated them first.
I think you got got.
lol that’s what I get for being post call😎
I think you got got.
lol that’s what I get for being post call😎
What do the surgeons want? Is there any input?
I'm assuming this is the trauma bay, not the OR? That's what I meant I guess.
Do yourself a favor and extricate an unstable patient from the ED as soon as possible. Last ruptured AAA i did came to me from the ED with a femoral a line and femoral triple lumen for an attempt at EVAR .
... thanks guys...
Do yourself a favor and extricate an unstable patient from the ED as soon as possible. Last ruptured AAA i did came to me from the ED with a femoral a line and femoral triple lumen for an attempt at EVAR .
... thanks guys...
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
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
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
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
... 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.
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
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?
Do yourself a favor and extricate an unstable patient from the ED as soon as possible. Last ruptured AAA i did came to me from the ED with a femoral a line and femoral triple lumen for an attempt at EVAR .
... thanks guys...
last one i got from the ED came up with a 22G IV. And the patient was in the ED for 2 hours
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.
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.
Frel free to share your amazing thoughts great em doctor
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
last one i got from the ED came up with a 22G IV. And the patient was in the ED for 2 hours
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.