Trauma Access

[deleted547339]

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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!

I don’t think it’s an argument of substandard care as much as the fact that a lot of people don’t understand what is or isn’t an appropriate expectation of an emergency department. A lot of people have the opinion that we should be as good as all subspecialists and should be completing non-emergent work ups and interventions. You seem to have reasonable/rationale expectations, but many people lack the 10,000 ft view and don’t understand that just because a patient needs an intervention/diagnostic/whatever doesn’t mean they need it before they go upstairs.

 

[deleted547339]

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.

Cool story.

 

[Hamhock]

Ithe 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!

I hear you.
Yet, this is exactly what vector2 was complaining about; a patient with the correct emergent diagnosis, the correct therapeutics, the correct consultant, and a functioning 18g. Vector2 used that as the example of failure.

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.

I know you are not vector2, but in this very thread the complaint was that a 18g IV was placed in a patient who needed "decent access". Other posters then went on to state that not having the patient intubated and a cordis placed was completely unacceptable. So, it is clear that you may "not (be) expecting a 14 or cordis, just put a 18g IV" but has been bashed in this very thread by others.

HH

 

[nimbus]

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...

I agree best way to manage these is to get them to the OR with some uncrossmatched blood ASAP. OR teams can focus on a single patient, we can do multiple tasks simultaneously on that patient, and we know what our needs and roles are.

I also agree that groin lines and 7fr triple lumens are inappropriate in these situations.

These patients need a NASCAR pit crew and the ED may not have the resources or culture to provide that.

 

[dchz]

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

Love how you quote my reply twice but read it 0 times.

so let me highlight the salient few sentences for you. glad you have backup.

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.

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.

 

[vector2]

I hear you.
Yet, this is exactly what vector2 was complaining about; a patient with the correct emergent diagnosis, the correct therapeutics, the correct consultant, and a functioning 18g. Vector2 used that as the example of failure.



I know you are not vector2, but in this very thread the complaint was that a 18g IV was placed in a patient who needed "decent access". Other posters then went on to state that not having the patient intubated and a cordis placed was completely unacceptable. So, it is clear that you may "not (be) expecting a 14 or cordis, just put a 18g IV" but has been bashed in this very thread by others.

HH

I don't need the ED to intubate or necessarily place a cordis, but a single 18g is not "decent access" in a ruptured AAA or type A dissection. If it was me or my family member sitting in the ED for 2hrs after the diagnosis I sure as sht would want at least 4 units matched, a 16g+16g and an a-line as soon as possible considering decompensation could happen at any second. You guys are telling me you're so busy with all your patients that you can't take 10-20 minutes to put in any lines, which presumably tells me the pt is going to be lucky to get a q15m reevaluation of the blood pressure and titration of drips, yet I'm supposed to be patting backs just because you got a CTA and paged surgery in a timely fashion?

Just last Friday I had an exsanguinating variceal bleeder come up to IR after hours for a TIPS. He had two 20g, one 18g, and a warming fem TLC. By the time I get him a couple hours after he's rolled in, he's intubated, blakemore in, still hypovolemic, profoundly acidotic, in SVT, and on 0.8 of levo (which the ED had connected to one of his peripherals instead of the TLC). Luckily it took about 20 seconds to change out the 18 to a RIC and start properly resuscitating him, but I've given up on the ED here putting in proper access unless it's a bonafide trauma and surgery is there to call out for 16gs if possible or do a fem cordis.

 

[Southpaw]

Perhaps some of the anesthesiologists here who have serious concerns should have a meeting with the ED physicians to discuss the pertinent patient care issues. The issues certainly won’t be solved here.

ED docs - most of you consider good jobs < 2pph in a SDG. I’m not an EM physician but I spent a month there in residency where I ‘moved the meat’. Your jobs are tough. No question. I wouldn’t want it. You consider yourselves the resuscitation experts and you will bill critical care time for these exsanguinaging patients. If you’re going to place a triple lumen, why not just place the cordis? We both know that’s the live saving intervention, along with surgery. If you’re the expert, do it.

 

[MoMoGesiologist]

I've sometimes noticed some specialties (outside of anesthesia) think a triple lumen catheter is "large bore access" and feel reassured by that...

And by some specialties I mean medicine. It was medicine

 

[anbuitachi]

Perhaps some of the anesthesiologists here who have serious concerns should have a meeting with the ED physicians to discuss the pertinent patient care issues. The issues certainly won’t be solved here.

ED docs - most of you consider good jobs < 2pph in a SDG. I’m not an EM physician but I spent a month there in residency where I ‘moved the meat’. Your jobs are tough. No question. I wouldn’t want it. You consider yourselves the resuscitation experts and you will bill critical care time for these exsanguinaging patients. If you’re going to place a triple lumen, why not just place the cordis? We both know that’s the live saving intervention, along with surgery. If you’re the expert, do it.

I've sometimes noticed some specialties (outside of anesthesia) think a triple lumen catheter is "large bore access" and feel reassured by that...

And by some specialties I mean medicine. It was medicine

Probably attending specific. In medicine when i first started i definitely saw more of this TLC type of thing for resuscitation. But over the past few years i feel like medicine has gotten much better at putting in introducers.
i think it's just the way they learn. medicine isn't focused on resuscitation.

These ppl exist everywhere. i've seen anesthesiologists do some really dumb things

 

[Southpaw]

These ppl exist everywhere. i've seen anesthesiologists do some really dumb things

Well that’s why I don’t like criticizing other physicians here or in general. We can have an educated discussion though on what’s best for patient care. I see anesthesiologists do dumb stuff all the time (mostly my opinion, and mostly to avoid work and/or conflict).

 

[Hamhock]

Since this thread has been derailed from the interesting discussion regarding trauma access, I will propose a solution to many of the complaints above. Granted, just like the anesthesiologists here don't know how ED staffing, flow, resource-management, etc works, I don't know how these systems work in the OR. So, the following proposal may not work...but I think it is an interesting exercise.

Let's take the aortic dissection case as an example.
After the tachycardic and hypertensive patient is discovered to have an aortic dissection, the ED rapidly titrates esmolol 300 and is working on titrating up nitroprusside. The surgeon has been notified and is coming to the ED to consult. Presumably when the "OR is notified" that means that anesthesiology is notified.

For this sick patient that needs intensive peri-operative management, should the anesthesiologist consult in the ED just like any other consultant would for a crashing patient? That way, while the patient is "just waiting" in the ED, lines, tubes, and resuscitation could all be performed exactly as the peri-operative specialist feels is best. Is this not the care you folks would want for your family member?

HH

 

[T-burglar]

Since this thread has been derailed from the interesting discussion regarding trauma access, I will propose a solution to many of the complaints above. Granted, just like the anesthesiologists here don't know how ED staffing, flow, resource-management, etc works, I don't know how these systems work in the OR. So, the following proposal may not work...but I think it is an interesting exercise.

Let's take the aortic dissection case as an example.
After the tachycardic and hypertensive patient is discovered to have an aortic dissection, the ED rapidly titrates esmolol 300 and is working on titrating up nitroprusside. The surgeon has been notified and is coming to the ED to consult. Presumably when the "OR is notified" that means that anesthesiology is notified.

For this sick patient that needs intensive peri-operative management, should the anesthesiologist consult in the ED just like any other consultant would for a crashing patient? That way, while the patient is "just waiting" in the ED, lines, tubes, and resuscitation could all be performed exactly as the peri-operative specialist feels is best. Is this not the care you folks would want for your family member?

HH

This is what I do Already for acute type A . I take some things with me in a bag and just go get the patient and bring them to the OR as fast as humanly possible. If anything blows in the ED or the elevator there’s nothing that even 20 introducers in every vein and the pericardium can fix .

 

[jeesapeesa]

Since this thread has been derailed from the interesting discussion regarding trauma access, I will propose a solution to many of the complaints above. Granted, just like the anesthesiologists here don't know how ED staffing, flow, resource-management, etc works, I don't know how these systems work in the OR. So, the following proposal may not work...but I think it is an interesting exercise.

Let's take the aortic dissection case as an example.
After the tachycardic and hypertensive patient is discovered to have an aortic dissection, the ED rapidly titrates esmolol 300 and is working on titrating up nitroprusside. The surgeon has been notified and is coming to the ED to consult. Presumably when the "OR is notified" that means that anesthesiology is notified.

For this sick patient that needs intensive peri-operative management, should the anesthesiologist consult in the ED just like any other consultant would for a crashing patient? That way, while the patient is "just waiting" in the ED, lines, tubes, and resuscitation could all be performed exactly as the peri-operative specialist feels is best. Is this not the care you folks would want for your family member?

HH

isn't that what the ED is for? triaging patients and stabilizing them for the next phase of care, especially a "crashing" patient? i would imagine this patient would be high on the list and needed more intervention time and care from the ER staff/physician than someone with a broken arm or a rash. i mean this thread is about trauma access and isn't trauma access the most essential part of a trauma case. if the ED has difficulty with accessing, i believe it is not unreasonable to call for help from the trauma surgeon (if available) or an available anesthesiologist if the patient is truly crashing. i think >=2 working 18G IVs is a good start and i would be happy to put a cordis once the patient reaches the OR.

 

[dchz]

For this sick patient that needs intensive peri-operative management, should the anesthesiologist consult in the ED just like any other consultant would for a crashing patient? That way, while the patient is "just waiting" in the ED, lines, tubes, and resuscitation could all be performed exactly as the peri-operative specialist feels is best. Is this not the care you folks would want for your family member?

This depends on the size of your ego.

If you legit think you need an anesthesiologist for access: Just send the pt up to the OR ASAP (which is what we've been asking for in this thread for a while now). why would you waste the pt's valuable time by adding additional trips for the anesthesiologist???

Instead of
step 1. recognize ruptured AAA
step 2. Consult anes
step 3. anes arrives in ed
step 4. pt goes to OR

Just do:
step 1. recognize ruptured AAA
step 2. pt goes to OR

If you let go of your ego and truly act as an expert in triage you'd see that cutting out the consult straight up saves lives. Again, SEND THE PT UP ASAP. We will gladly take the pt off your hands and turf the meat for you while you attend to your other "crashing" patients. This is a win-win-win (for the pt, ED, and OR teams)

 

[dchz]

This is what I do Already for acute type A . I take some things with me in a bag and just go get the patient and bring them to the OR as fast as humanly possible. If anything blows in the ED or the elevator there’s nothing that even 20 introducers in every vein and the pericardium can fix .

This can be improved upon if there is an agreement that ED just sends them up to the OR ASAP after calling the consult, it saves you the trip and it's important time for the pt.

 

[drmwvr]

Like not expecting a 14 or cordis, just put a 18g IV!

All a patient needs to go to sleep or be given a little ketamine is an IV, even a 22. To be fair, getting any meaningful peripheral in a vasculopath with a ruptured AAA or aortic dissection in extremis in the ED can be a bridge too far in a lot of cases. There is no meaningful resus in these types of patients without a cordis anyway, so putting in an awake-ish or immediate post induction neck line needs to be done one way or the other.

I could care less what size IV the patient comes up with. I'm grateful for anything that works. I'm not going to use it for more than 90 seconds anyway.

 

[anbuitachi]

All a patient needs to go to sleep or be given a little ketamine is an IV, even a 22. To be fair, getting any meaningful peripheral in a vasculopath with a ruptured AAA or aortic dissection in extremis in the ED can be a bridge too far in a lot of cases. There is no meaningful resus in these types of patients without a cordis anyway, so putting in an awake-ish or immediate post induction neck line needs to be done one way or the other.

I could care less what size IV the patient comes up with. I'm grateful for anything that works. I'm not going to use it for more than 90 seconds anyway.

Well one reason i said 18g IV is b/c i want the patient up ASAP. Now if the patient has really bad veins, and if 22 G is the best they could do, that's fine. I dont expect a >18 even though id love to have one because i dont know how experienced the person down there is at any given moment. id rather myself place a 14G IV than them trying and risking blowing all the veins and leaving me with barely anything. Having intact veins is also pretty helpful for converting to a RIC line. Ideally in a case with high risk massive blood loss i prefer to have 1 introducer and 1 RIC

though on a side note, a lot of delays i've noticed with patient coming up from the ED has to do with ancillary staff. often times transporter or whatnot or nurse having to fill out forms etc. a lot of times bedside nurses may not be the best at triaging, or very big on following doctors orders (ok). they may not be sending patient up until they draw those labs that the MD ordered or whatever, even though i could care less about those labs and can do them faster upstairs if i need to

 

[Hamhock]

Well one reason i said 18g IV is b/c i want the patient up ASAP. Now if the patient has really bad veins, and if 22 G is the best they could do, that's fine. I dont expect a >18 even though id love to have one because i dont know how experienced the person down there is at any given moment. id rather myself place a 14G IV than them trying and risking blowing all the veins and leaving me with barely anything. Having intact veins is also pretty helpful for converting to a RIC line. Ideally in a case with high risk massive blood loss i prefer to have 1 introducer and 1 RIC

though on a side note, a lot of delays i've noticed with patient coming up from the ED has to do with ancillary staff. often times transporter or whatnot or nurse having to fill out forms etc. a lot of times bedside nurses may not be the best at triaging, or very big on following doctors orders (ok). they may not be sending patient up until they draw those labs that the MD ordered or whatever, even though i could care less about those labs and can do them faster upstairs if i need to

This.
I am an intensivist. I get called for just about every crashing patient in the ED.
Even if I have an open bed and let the ICU charge know I want the patient up ASAP, it will take at least 30 minutes!
In that time, I can get down to the ED and stabilize most patients. The value of showing up in the ED and resuscitating beyond what the average EM doc can do is measured, I am convinced, in lives in some cases.
I am sure the same would be true for pre-operative crashing patients if the anesthesiologist consulted ASAP to the ED. I know this because at one of my hospitals, I am often called for type As. I can get down there and get access and guide pre-operative therapy before the OR transport staff gets in the elevator on their way to the ED.

This can be improved upon if there is an agreement that ED just sends them up to the OR ASAP after calling the consult, it saves you the trip and it's important time for the pt.

If the anesthesiologist doesn't want to consult in the ED, a program like dchz described can be initiated. This takes some work and input from EM docs, anesthesiologists, and surgeons.

The same community hospital I referenced above is trying to improve their trauma program. The data they collected for transport from the ED to the OR after the surgeon makes the decision that the OR is needed showed times frequently >30 minutes (even worse when the patient is intubated in the ED). This really had nothing to do with the EM docs or the surgeons. Rather, it was a systems problem that required manager input and ancillary staff improvements.

Although I haven't seen any summary data, the monthly case reviews are showing ED to OR times less than ten minutes, which is pretty incredible, when you think about it.

I am sure similar arrangements could be made for other crashing surgical cases. In fact, I will think how we could do this at my hospital. Interestingly, some of the ways to make things quicker it seems to include not intubating in the ED if possible and to just get adequate PIV access and then start transporting. If I had to set up a system for type A at our hospital, I would recommend 18g PIV, esmolol/nitroprusside, and no ETT or aline -- then transport. Dicking around in the ED will just delay things.

HH

 

[Echo33]

Love how you quote my reply twice but read it 0 times.

so let me highlight the salient few sentences for you. glad you have backup.

Hey, yeah I read what you wrote.

Do agree that patients with these issues should come to the OR ASAP. I just haven’t found, in my experience, that the cause of delay from ER to OR is woeful incompetence in line placement (or ego or stubbornness like you said).

Didn’t mean to get you fired up over this. I was just tryin to stick up for the guys in the trentches. We have a pretty good relationship with them. Sounds like you have a pretty crummy opinion of them, based on the tone of your posts.

 

[vector2]

Ruptured AAA and type A's aren't like traumas in most places, in that at a level I trauma center there's usually an OR that's ready and there's a trauma surgeon in house ready to cut at a moments notice. The aforementioned cases inevitably end up taking 1-2h to make it to the OR cause the attending surgeon (and frequently the cardiac anesthesia team) need to come in from home. In my CCM fellowship we essentially just bypassed the ED by having the CTS fellow admit them up to the CTICU as quickly as possible where we would start whatever drips and lines we wanted.

 

[alpinism]

Why are people still putting in Cordis lines?

We stopped using them a long time ago at our trauma center ( >3,000 traumas per month).

2 x14G provide almost twice the flow and can be placed in less than 30 seconds by experienced providers.

Hell in the time it takes you to put in a cordis I could give 2 units of blood, take a dump, and go smoke a cigarette.

 

[anbuitachi]

Why are people still putting in Cordis lines?

We stopped using them a long time ago at our trauma center ( >3,000 traumas per month).

2 x14G provide almost twice the flow and can be placed in less than 30 seconds by experienced providers.

Hell in the time it takes you to put in a cordis I could give 2 units of blood, take a dump, and go smoke a cigarette.

not everybody got veins to take in 14G ivs....

 

[nimbus]

Why are people still putting in Cordis lines?

We stopped using them a long time ago at our trauma center ( >3,000 traumas per month).

2 x14G provide almost twice the flow and can be placed in less than 30 seconds by experienced providers.

Hell in the time it takes you to put in a cordis I could give 2 units of blood, take a dump, and go smoke a cigarette.

Cordis doesn’t infiltrate. Can give vasopressors.

 

[MoMoGesiologist]

Why are people still putting in Cordis lines?

We stopped using them a long time ago at our trauma center ( >3,000 traumas per month).

2 x14G provide almost twice the flow and can be placed in less than 30 seconds by experienced providers.

Hell in the time it takes you to put in a cordis I could give 2 units of blood, take a dump, and go smoke a cigarette.

PIVs are fine in the OR. I don't think I would trust the nurses in the ICU with them. I think a cordis will help with postoperative management.

 

[bigdan]

Why are people still putting in Cordis lines?

We stopped using them a long time ago at our trauma center ( >3,000 traumas per month).

2 x14G provide almost twice the flow and can be placed in less than 30 seconds by experienced providers.

Hell in the time it takes you to put in a cordis I could give 2 units of blood, take a dump, and go smoke a cigarette.

Instead of Cordis lines or 14g IVs, I'd advocate for more helmets and better drivers. Your hospital averages 100 traumas A DAY???
Shock Trauma does <8000 per year!
Which hospital are you at?

 

[nimbus]

Instead of Cordis lines or 14g IVs, I'd advocate for more helmets and better drivers. Your hospital averages 100 traumas A DAY???
Shock Trauma does <8000 per year!
Which hospital are you at?

We count little old ladies on plavix who bump their head. Maybe they do too.

 

[T-burglar]

Why are people still putting in Cordis lines?

.

Because people are still doing major surgery

 

[anbuitachi]

what are you people doing for transfusion in terms of warming? dump everything in the belmont or separate (eg platelets). How fast do you give your desmopressins?

 

[T-burglar]

For massive transfusion I typically put reds and plasma in the Belmont and use a separate unwarned blood set with a pressure bag for platelets.

I try as hard as I can to test the underbody bair hugger before draping to make sure the whole thing inflates with the patient on it. Then I often do a lower body in addition ( two bair huggers ). I don’t usually give desmo unless the patient is uremic or has severe AS

 

[vector2]

what are you people doing for transfusion in terms of warming? dump everything in the belmont or separate (eg platelets). How fast do you give your desmopressins?

Avoiding warming platelets is a myth assuming your fluid warmer is at a normalish temp (38-40C) and not crazy hot. I give everything through our warmers.

"Extreme warming of platelets (>43-45 degrees C) has been shown to impair platelet aggregation and to alter cytoskeletal membrane components.ii,iii Manufacturers of fluid warming devices generally do not recommend infusing platelets through such a device, although data are scarce that would suggest that infusion through these warming devices is detrimental to platelet function"

https://www.asahq.org/~/media/sites...asa committees/plate cobm asa final.pdf?la=en


Stored platelet functionality is not decreased after warming with a fluid warmer. - PubMed - NCBI

 

[Psai]

Why warm something when you don't need to

 

[vector2]

Why warm something when you don't need to

For the average big belly case or heart I've stopped placing a second large PIV since the advent of the MAC cordis and 12fr TLCs. I would rather get my platelets in quickly on the warmed blood tubing that's connected to the big line rather than wait for them to trickle in on whatever 20g they came with from preop.