Unable to gain intravenous access in a pt bleeding out, what's the next step?

[wickedskillz]

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When I was a med student on call at the ER, we had a hemophiliac who had gotten himself into a motorcycle accident and was bleeding profusely from multiple sites. His veins were so small that nobody was able to get an I/V in, and I thought he might bleed out until someone finally got a line going. I was wondering what the next step would be if we had failed at gaining I/V access altogether? How could you transfuse? Are there clear guidelines for which step to follow next or is it more of an attending's personal choice? I was unable to ask my attending so I was hoping someone here could help.

Thanks a lot!

 

[turkeyjerky]

IO or Central Access (i'd avoid subclavian in this guy)

 

[Acoustic Shadow]

1. Consider and EJ
2. US Guided PIV
3. CVL - with US guidance if the pt is very dehydrated. Dont use a non-compressible site like SCV in pt with bleeding d/o


If the pt is indeed bleeding out, hypotensive, unstable and you cannot rapidly start a PIV - I/O access should be done ASAP.

 

[Greenbbs]

If theyre truly unstable and bleeding out, hypotensive, etc, I'd US in an introducer and use that to get blood and fluids in. Using the US in the properly trained hands can minimize excessive pokes and prodding and decrease the chance of further injury.

 

[tcp03]

If you're in the ACLS or PALS Asystole/PEA/V-FIB/Pulseless V-Tach protocol and you can't get and IV in 30 seconds throw down the I.O....very easy just don't do it too many times or you'll make swiss cheese out of the bone and "start another leak" so to speak...if that doesn't work which I can't see why it wouldn't then go central line or if you wan't to be barbaric (I don't even know if they still do this in some centers) you can do a saphenous venous cut down. just land the I.O and you'll be A-OK most of the time. Good luck!

 

[wickedskillz]

Appreciate the fast replies guys! Unfortunately, I haven't seen an IO line being placed before. Are they a) fast? b) readily available in most ERs and wards??

 

[wickedskillz]

I just saw some medscape videos on how to place them. man do they look painful :/

 

[xaelia]

I just saw some medscape videos on how to place them. man do they look painful :/

They are similarly painful to a single attempt at a large-bore peripheral IV. IO reps will frequently self-administer IOs during demonstrations. They're a great option and underutilized in many settings.

 

[Cerberus]

If you cant get PIV access i'd go straight to either an IO or an US guided femoral line (definitely avoid the subclavian in a pt like this). If the pt is a hemophilliac who is bleeding out I wouldn't waste too much time trying to get a piddly 20-22g IV via US. I've seen excellent US trained attendings struggle to get U/S guided peripherals in some patients with crappy vasculature.

 

[future_dr_house]

Appreciate the fast replies guys! Unfortunately, I haven't seen an IO line being placed before. Are they a) fast? b) readily available in most ERs and wards??

Fast and really easy. The last one I did took about 3 seconds with the power drill that comes with the package. I imagine all places would have them available because they are the standard go-to after failed IV attempts in peds.

In terms of that acutely hemorrhaging patient, I'd probably try
1) EJ
2) IO
3) After either of those are in, I'd try a cordis introducer because you've bought yourself a little time with EJ or IO
4) If all those fail, cut down

US guided PIV in my experience is great for someone with good preload, but in a hemorrhagic shock I wouldn't waste my time, those veins are going to be collapsed more often than not

 

[gro2001]

To echo what others have said so far...

If bleeding but not crashing just yet
1) peripheral IV
2) EJ
3) IJ (with US) or femoral cordis (blind)
4) IO

If crashing
1) peripheral IV
2) either IO or femoral cordis (whichever kit can be at the bedside faster)

If for some reason IO is not available and can't get cordis, saphhenous venous cutdown.

 

[Dirae]

Oops, we missed the OPs follow up question.

An IO is an intraosseous needle. Essentially its a needle that's ususally 30 or 45mm long that goes into bone. The needle goes intramedullary space to the marrow cavity. They can either be pushed in by hand, or at my place we use EZ IO, where its basically on a power drill and you just squeeze the trigger for a second till its in.

Basically, you can run anything through an IO that you can through a central line, blood, pressors, fluids etc. You can also draw any labs except a CBC, because platelets and WBC counts will be off since you're drawing from marrow.

 

[gro2001]

Oops, we missed the OPs follow up question.

An IO is an intraosseous needle. Essentially its a needle that's ususally 30 or 45mm long that goes into bone. The needle goes intramedullary space to the marrow cavity. They can either be pushed in by hand, or at my place we use EZ IO, where its basically on a power drill and you just squeeze the trigger for a second till its in.

Basically, you can run anything through an IO that you can through a central line, blood, pressors, fluids etc. You can also draw any labs except a CBC, because platelets and WBC counts will be off since you're drawing from marrow.

Also, the advantage of the IO is that no matter who fluid down they are, the marrow space never collapses.

 

[EctopicFetus]

Also, whoever said they hurt like a peripheral IV must be joking. Having placed a number of them I can assure you they hurt much more than a PIV.

Havent done one in a while though.

 

[BADMD]

If he is truly "bleeding out" than an IO is super crappy choice. They are small bore and frequently won't drip without being under pressure.

In this case, I might drop an IO and start dumping in factor while I set up for something big. Or, I might go straight for the introducer and chase rapidly with factor.

 

[diphenyl]

If patient is about to arrest from hypovalemia regardless of whether or not they have hemophilia my order goes as such:

1. large bore periphreal IV
2. EJ
3. IJ or Femoral central line, preferably a cordis aka single lumen (use ultrasound if the low bp has made their veins clamp down)
4. saphenous Cut down (if they are truly about to die even if they don't clot your not hurting them any worse by doing one)

IO is only good for emergent access when you just really need to give cardiac drugs, doesn't really do jack for the unstable trauma patient.

 

[deleted6669]

I was at a cme for the ez-io in march. the ceo of the company was giving the talk. a doc in the audience asked him how much it hurt and he allowed him to start one in his humerus right then and there. guy didn't flinch. kept lecturing during the procedure.
that being said the same folks who scream and yell when you put in a 24g iv will scream and yell with an io( or a td or a steristrip).
ps don't forget the atls option of the saphenous cutdown. relatively quick if you do a lot and can't do an io for whatever reason.

 

[BADMD]

a doc in the audience asked him how much it hurt and he allowed him to start one in his humerus right then and there. guy didn't flinch. kept lecturing during the procedure.

I'd like to see what he does when some fluid gets pushed through it.

I try to slowly push some lidocaine through them once the initial stuff goes down it.

 

[Dirae]

agreed an IO is a crappy choice for a GI bleeder or someone who needs large transfusion. However, I think the IO can still be a great option while you're trying a femoral cordis. Had an interesting case a few weeks ago where the patient had a pelvic compartment syndrome, so me, the PGYIII, and eventually the intensivest attending himself couldn't get a femoral because it was so compressed. Tibial IO really saved us for a while.

As far as pain, everyone responds differently, and I would guess it does hurt but on every one I've put in, it was in a really sick obtunded patient anyways.

Edit: We couldn't go for an IJ or SC because we were messing with trying to get the blakemore in up top. Those freaking things are a pain.

 

[Hamhock]

I was at a cme for the ez-io in march. the ceo of the company was giving the talk. a doc in the audience asked him how much it hurt and he allowed him to start one in his humerus right then and there. guy didn't flinch. kept lecturing during the procedure.

There used to be (probably still) a bunch of videos (you tube and such) of people - mostly EMS, interestingly - putting IOs into themselves or others just for practice.

HH

 

[bulgethetwine]

IO or Central Access (i'd avoid subclavian in this guy)

I'd try a femoral central line first, and a subclavian second.

I can put in either one in under 60 seconds. While the medicine resident is hunting for the ultrasound, I've already done the subclavian. But, then I had the "benefit" of training before everyone insisted on using ultrasound for everything. Tough to learn the skill now.

Tough to transfuse adequately through an I/O

 

[xaelia]

No limit to the # of IOs you put in if you don't think you have enough resuscitation access with your first one. Well, limited by the # of limbs.

I wouldn't waste time hunting for an EJ in an unstable or even pre-unstable patient. If large-bore peripheral access is a dead end, IO temporizing until cordis. Can next go high line of choice either urgently or semi-urgently depending on clinical context.

 

[Arch Guillotti]

I'd try a femoral central line first, and a subclavian second.

Subclavian before IJ in a hemophiliac? Interesting. Is it because you are more facile with the subclavian I guess?

 

[medic25]

You'll also get a much better flow rate with the EZ-IO if it's inserted into the humerus rather than the tibia. The figure I heard quoted was that a humeral IO had flow rates equivalent to a 16g peripheral vs. 20-22g in the tibia; having pushed fluids through both sites I'd agree that flow into the humerus was much faster and easier.

 

[medic25]

I wish I had known about this sooner, because we learned it the hard way in Afghanistan.

Originally we thought it would be more technically challenging to place it in the proximal humerus, so were putting them in the tibia. After a few cases where we could push fluid with a 60cc syringe but couldn't get a drip, we started doing humerus, and it flowed like a dream. This occurred even though the gauges were the same, and the patient was supine. I still don't understand the difference, but I lived it firsthand as well.

I attending a 2-day Vidacare seminar in San Antonio last year and took away a lot of information. The thought was that the humerus is typically a less compact bone; the tibia is constantly bearing the body's weight, which over time compresses the bone and makes for a tighter medullary space. Since the humerus hasn't had gravity and body weight to contend with, it's much easier to rapidly push in the fluids without a lot of resistance.

Another tip I took away to increase flow rates that's frequently forgotten is to rapidly flush 10cc into the IO with a syringe before trying to flow IV fluids; it seems to open things up and allow the IV to flow much more freely. I see a lot of people insert the needle, aspirate some marrow and directly attach the IV tubing, and then wonder why the fluids are barely flowing.

 

[xaelia]

Sternal IO is better than tibial IO for rapidity of drug reaching peak concentration in arterial circulation and reaches a higher peak - in pigs, anyway. I'd imagine the humerus is also superior to the tibia, but now we're extrapolating another step out from the evidence.

http://emlitofnote.blogspot.com/2011/09/sternal-io-is-best-io.html

 

[EctopicFetus]

Lots of issues with the sternal IO which is why I believe I have never done it myself nor seen it done.

 

[xaelia]

I wouldn't typically consider a sternal IO either - just happened to be the site used in what I'd read recently.

 

[gro2001]

I wouldn't typically consider a sternal IO either - just happened to be the site used in what I'd read recently.

I hear that's what they use in the military. Makes sense, if you are going to teach your medics one protocol, it should be something that can be used on anyone. Including people with arms/legs blown off.

 

[NinerNiner999]

Peripheral IO can flow fluids under pressure at a rate of 7-8 liters / hr. Those placed more centrally (proximal humerus) have been shown to flow up to 12-14 L/HR. They are very effective for volume resuscitation and cardiac arrest, and also shown to be safer than central access in "dangerous" patients (high INR, hemophiliac, etc). I think it is a great option.

 

[bulgethetwine]

Subclavian before IJ in a hemophiliac? Interesting. Is it because you are more facile with the subclavian I guess?

Yeah. That's the only reason really. If I *do* have the luxury of time then I'd have to agree that the safest line is the IJ under ultrasound (if I didn't do the femoral, which I would in a hemophiliac as 1st choice, even with the infection risk inherent to femoral lines.... I can always change it later once stable).

But the subclavian I know I can slam in in 30-60 seconds - I've done over a 200 of them I'd guess - and I know the anatomy is much more consistent than an IJ.

Incidentally, it might be old school, but in a truly emergent case, I wouldn't wait for an ultrasound even if I was going for the IJ. It wasn't that long ago EM residents all across the country were learning and doing IJ by landmarks..... I think it's a lost art 🙁

 

[Arch Guillotti]

Agree, the ultrasound is not always there when you need it.

Yeah. That's the only reason really. If I *do* have the luxury of time then I'd have to agree that the safest line is the IJ under ultrasound (if I didn't do the femoral, which I would in a hemophiliac as 1st choice, even with the infection risk inherent to femoral lines.... I can always change it later once stable).

But the subclavian I know I can slam in in 30-60 seconds - I've done over a 200 of them I'd guess - and I know the anatomy is much more consistent than an IJ.

Incidentally, it might be old school, but in a truly emergent case, I wouldn't wait for an ultrasound even if I was going for the IJ. It wasn't that long ago EM residents all across the country were learning and doing IJ by landmarks..... I think it's a lost art 🙁

 

[Janedoedoctor]

Yeah. That's the only reason really. If I *do* have the luxury of time then I'd have to agree that the safest line is the IJ under ultrasound (if I didn't do the femoral, which I would in a hemophiliac as 1st choice, even with the infection risk inherent to femoral lines.... I can always change it later once stable).

But the subclavian I know I can slam in in 30-60 seconds - I've done over a 200 of them I'd guess - and I know the anatomy is much more consistent than an IJ.

Incidentally, it might be old school, but in a truly emergent case, I wouldn't wait for an ultrasound even if I was going for the IJ. It wasn't that long ago EM residents all across the country were learning and doing IJ by landmarks..... I think it's a lost art 🙁

'Slamming' in a subclavian in a severely hypovolemic hemophiliac
It's not 2nd choice, it's 7th (2 femorals, 2 tibias and 2IJ's to burn before you get to the subclavian)

You are right about the ultrasound not being there when it is needed most. The only sensible lines in this situation are imho the femoral or IO.

That's 4 possible safe sites for quick line placement.

 

[TrustMe]

In a hypotensive, unstable, coagulopathic trauma pt. in my opinion,
1. Rt. femoral introducer
2. Lt. femoral introducer
3. Rt. IJ introducer
4. Lt. IJ introducer
5. Anything else someone can get into any vein
6. IO

Not every place stocks them, but my favorite volume line is the 9Fr. MAC line. Two large volume ports allows you to give multiple products at the same time. It also has an introducer port that you can put a cutoff SLIC through for a third volume port. Or a 12Fr. temporary dialysis catheter, great for volume.

 

[bulgethetwine]

'Slamming' in a subclavian in a severely hypovolemic hemophiliac
It's not 2nd choice, it's 7th (2 femorals, 2 tibias and 2IJ's to burn before you get to the subclavian)

You are right about the ultrasound not being there when it is needed most. The only sensible lines in this situation are imho the femoral or IO.

That's 4 possible safe sites for quick line placement.

I can't say that I think you're wrong. We would both be standard of care. But I've put in 200 subclavians, on many coagulopathic, hypovolemic patients with very little downside/complications.

For me, it is merely one way to skin the cat. You've offered a completely viable alternative (several, actually), and for you, perhaps a subclavian is just something you don't want to do. Fair play, and I respect that fully.

I only mention my perspective so as to avoid the slip into dogma whereby various non-physicians, risk-managers, lawyers, etc. might someday think that somehow a subclavian is NOT standard of care.

The best line in a crashing patients remains the one you are most comfortable with.

Respectfully,

BTT

 

[bulgethetwine]

In a hypotensive, unstable, coagulopathic trauma pt. in my opinion,
1. Rt. femoral introducer
2. Lt. femoral introducer
3. Rt. IJ introducer
4. Lt. IJ introducer
5. Anything else someone can get into any vein
6. IO

Not every place stocks them, but my favorite volume line is the 9Fr. MAC line. Two large volume ports allows you to give multiple products at the same time. It also has an introducer port that you can put a cutoff SLIC through for a third volume port. Or a 12Fr. temporary dialysis catheter, great for volume.

I think it bears repeating that the subclavian anatomy is much more consistent than the IJ. So while you might list IJ very high, in the absence of ultrasound but in the presence of an experienced subclavian jockey, the subclavian is actually much less likely to result in arterial puncture.

And yes, I'm aware that you could argue that an IJ is "compressible" while the subclavian isn't (hell, before ultrasound, we used to hit the IJA quite a bit.... held pressure, hardly remember any complications) but even in my small number of arterial sticks in the subclavian site, pressure was able to be applied without any untoward event (including a guy with an INR of 6 once s/p cardiac surgery 🙁

I feel like I'm the Champion of Subclavians all of a sudden 🙄

I swear, I'm not meaning to sound so biased toward subclavians! I do a lot of IJs under ultrasound to be fair. But the subclavian is an important part of your tool box, I believe, for a multitude of reasons: infection risk in femoral, steric hindrance from c-spine collar as regards access to IJ, more consistent anatomy, etc.

And I fear that it is a vanishing tool for our EM trainees 🙁

 

[wickedskillz]

This discussion has been most educational! Thanks a lot for your help everyone.

 

[Janedoedoctor]

I think it bears repeating that the subclavian anatomy is much more consistent than the IJ. So while you might list IJ very high, in the absence of ultrasound but in the presence of an experienced subclavian jockey, the subclavian is actually much less likely to result in arterial puncture.

And yes, I'm aware that you could argue that an IJ is "compressible" while the subclavian isn't (hell, before ultrasound, we used to hit the IJA quite a bit.... held pressure, hardly remember any complications) but even in my small number of arterial sticks in the subclavian site, pressure was able to be applied without any untoward event (including a guy with an INR of 6 once s/p cardiac surgery 🙁

I feel like I'm the Champion of Subclavians all of a sudden 🙄

I swear, I'm not meaning to sound so biased toward subclavians! I do a lot of IJs under ultrasound to be fair. But the subclavian is an important part of your tool box, I believe, for a multitude of reasons: infection risk in femoral, steric hindrance from c-spine collar as regards access to IJ, more consistent anatomy, etc.

And I fear that it is a vanishing tool for our EM trainees 🙁

I highly respect your experience with subclavian acces, and I don't doubt that in the hands of an experienced operator, it's quite safe.

But there are 2 problems with this: firstly, most people here aren't as experienced (it's a residents forum after all). While on the learing curve, arterial sticks are unavoidable.
Secondly, when litigation is concerned, going for the subclavian as your first attempt in a patient with a well known severe coagulation disorder is indefensible. If you have a complication, you're basically screwed.

Your concerns about infection problems with femoral acces are valid but not applicable to an acute situation. In the ICU, that line will have to be replaced sooner than one in another site, but that is not a concern while the patient is actively crashing.

I agree with you on 'blind' IJ's being relatively safe. I have done quite a lot of them and there are few complications from arterial sticks if you take the time to hols pressure properly when you notice it.

 

[TrustMe]

I agree that the subclavian site is a great line site (lower infection rates, more patient comfort, more reliable anatomical location). However, one of the relative contraindications for this site is pt. with a coagulopathy. In an emergent situation "relative" can become a very soft call. I also agree that in some places the subclavian site is being used less and less due to the preference for U/S guidance. Where I trained I felt like our attendings preferred IJ's because we could use U/S and they could gain comfort in seeing exactly where we were with our needle. I felt like this was only for their comfort, not for my education. I had to seek out attendings that would let me place subclavian lines and thus I did not do a lot. As a fellow now in the ICU I try and place subclavian lines unless the pt. is coagulopathic. We also have a new attending that was trained to place subclavians with U/S guidance. This is less helpful in emergent situations but can offset the coagulopathy contraindication when placing a subclavian line. It's a little awkward at first, but is a great tool to have in your bag.

 

[docB]

I've never done a cut down (except cadavers). I don't know that I could do it when the chips were down. With IOs now I would probably try that several times before I even considered a cut down.

 

[Zanegray]

I'd like to see what he does when some fluid gets pushed through it.

I try to slowly push some lidocaine through them once the initial stuff goes down it.

We do prehospital stuff at our residency including helicopter and I have used IO quite often. I think they work great for initial resuscitation, but they hurt like hell... When anything is infused. We had a near amputation of lower extremity due to MCC and uncontrolled bleeding. No peripheral access. Started an IO, pushed some lidocaine followed by NS under pressure, and the patient, who had been doing ok in terms of pain with a severe crush injury, began screaming!

 

[iridesingltrack]

In the scenario presented by the OP this is a blunt traumatic mechanism but remember that were this penetrating to the box a femoral line is much less desirable. I agree with BTT in regards subclavian lines. They must be something we can quickly put in anyone, anytime.

If we dont practice the skill then we wont have it when we need it. With that said, don't practice on the coagulopathic patient but this patient is dying and I am a strong advocate for any port in a storm.

Also, anyone doing much supraclavicular subclavian lines? I have done a few and like them. They are theoretically at a compressible site, may be ultrasound guided, are not flumixed by c-collars, and do not interfere with anything going on on the pts chest (like CPR).

Iride

I agree that the subclavian site is a great line site (lower infection rates, more patient comfort, more reliable anatomical location). However, one of the relative contraindications for this site is pt. with a coagulopathy. In an emergent situation "relative" can become a very soft call. I also agree that in some places the subclavian site is being used less and less due to the preference for U/S guidance. Where I trained I felt like our attendings preferred IJ's because we could use U/S and they could gain comfort in seeing exactly where we were with our needle. I felt like this was only for their comfort, not for my education. I had to seek out attendings that would let me place subclavian lines and thus I did not do a lot. As a fellow now in the ICU I try and place subclavian lines unless the pt. is coagulopathic. We also have a new attending that was trained to place subclavians with U/S guidance. This is less helpful in emergent situations but can offset the coagulopathy contraindication when placing a subclavian line. It's a little awkward at first, but is a great tool to have in your bag.

 

[bulgethetwine]

I highly respect your experience with subclavian acces, and I don't doubt that in the hands of an experienced operator, it's quite safe.

But there are 2 problems with this: firstly, most people here aren't as experienced (it's a residents forum after all). While on the learing curve, arterial sticks are unavoidable.
Secondly, when litigation is concerned, going for the subclavian as your first attempt in a patient with a well known severe coagulation disorder is indefensible. If you have a complication, you're basically screwed.

Your concerns about infection problems with femoral acces are valid but not applicable to an acute situation. In the ICU, that line will have to be replaced sooner than one in another site, but that is not a concern while the patient is actively crashing.

I agree with you on 'blind' IJ's being relatively safe. I have done quite a lot of them and there are few complications from arterial sticks if you take the time to hols pressure properly when you notice it.

Good reply.

I think you're right that a lot of people aren't as experienced with subclavians. This, actually, is a point I'm trying to make. We can't lose this art!

Oddly enough, my experience has been that the main problem with inexperienced people trying to do subclavians isn't art sticks but typically failure to get any flash -- the text books describe an approach that is really too far lateral for some patients.... many experienced providers end up adopting a modified technique where they enter more medially than the books illustrate. Arterial sticks are rarer than one might surmise at this site -- the anatomy is remarkably consistent, the vein is almost always tethered to the underside of the middle to medial 1/3 of the clavicle.


Your point on litigation is also spot on. I probably mangled it a little bit in the thread - I agree that femoral would be my first choice in the scenario above, infection risk be damned (though I'd try and be as sterile as possible, of course) because we can change it out in the unit. But I don't think a subclavian would be out of line -- even in a coagulopathic patient -- should the femoral not be an option for some reason (I swear to God - where I trained there were more than a few one-legged vasculopaths) 😳

Remember, litigation judgements are based on negligence. A judgement call to go for a subclavian after the femoral route is ruled out is actually easily justified in many instances relative to an IJ, particularly if you work in an ED that doesn't have bedside ultrasound... and there's more of those EDs out there beyond the walls of our academic institutions than we often realize!

Regards,

BTT

 

[bulgethetwine]

In the scenario presented by the OP this is a blunt traumatic mechanism but remember that were this penetrating to the box a femoral line is much less desirable. I agree with BTT in regards subclavian lines. They must be something we can quickly put in anyone, anytime.

If we dont practice the skill then we wont have it when we need it. With that said, don't practice on the coagulopathic patient but this patient is dying and I am a strong advocate for any port in a storm.

Also, anyone doing much supraclavicular subclavian lines? I have done a few and like them. They are theoretically at a compressible site, may be ultrasound guided, are not flumixed by c-collars, and do not interfere with anything going on on the pts chest (like CPR).

Iride

I've done some supraclavicular... I find them useful in big, barrel chested COPD patients. I had a mentor give me some advice that has always stood me well: Whereas you walk down the clavicle in a subclavian, in a supraclavicular, you start some distance away from the clavicle but quite inferior to it so that you are always advancing the needle upward. I position it so that the point of the needle just skirts the underside of the clavicle - again, trying to take advantage of that extremely consistent anatomical tethering of vein to underside of bone.

 

[Lawsonc]

I attending a 2-day Vidacare seminar in San Antonio last year and took away a lot of information. The thought was that the humerus is typically a less compact bone; the tibia is constantly bearing the body's weight, which over time compresses the bone and makes for a tighter medullary space. Since the humerus hasn't had gravity and body weight to contend with, it's much easier to rapidly push in the fluids without a lot of resistance.

Another tip I took away to increase flow rates that's frequently forgotten is to rapidly flush 10cc into the IO with a syringe before trying to flow IV fluids; it seems to open things up and allow the IV to flow much more freely. I see a lot of people insert the needle, aspirate some marrow and directly attach the IV tubing, and then wonder why the fluids are barely flowing.

Flushing and don't forget to aspirate. I've seen firefighters squeezing saline bags with no result, get that syringe out and aspirate/flush and it was no problem after.


I like the IO, its brought some unconcious patients back to life (not due to actual fluid but the initial bolus) , and for others with a little bit of a lido bolus it was pain free.

 

[Lawsonc]

Yeah. That's the only reason really. If I *do* have the luxury of time then I'd have to agree that the safest line is the IJ under ultrasound (if I didn't do the femoral, which I would in a hemophiliac as 1st choice, even with the infection risk inherent to femoral lines.... I can always change it later once stable).

But the subclavian I know I can slam in in 30-60 seconds - I've done over a 200 of them I'd guess - and I know the anatomy is much more consistent than an IJ.

Incidentally, it might be old school, but in a truly emergent case, I wouldn't wait for an ultrasound even if I was going for the IJ. It wasn't that long ago EM residents all across the country were learning and doing IJ by landmarks..... I think it's a lost art 🙁

12 gauge, find the sternal notch, two fingers up, two fingers to the side and point towards the toe/nipple? It worked for King County Medic 1 out in the field!

I have not worked in a system that allows central lines in the field, but our instructors came from counties that did, we learned the down and dirty on the IJ and sub clav, but I would feel more comfortable doing the IJ versus the sub clav if I had to (blindly in the field)

 

[bulgethetwine]

12 gauge, find the sternal notch, two fingers up, two fingers to the side and point towards the toe/nipple? It worked for King County Medic 1 out in the field!

I have not worked in a system that allows central lines in the field, but our instructors came from counties that did, we learned the down and dirty on the IJ and sub clav, but I would feel more comfortable doing the IJ versus the sub clav if I had to (blindly in the field)

Well, if you're more comfortable with an IJ vs. SC, then that's the only justification you need to do it first in an emergency.

But just out of curiosity, why?

Incidentally, if you go just two fingers up and two to the side heading toe-ward, there's a good chance you did a supraclavicular SC a fair few times! 😉

 

[Lawsonc]

Well, if you're more comfortable with an IJ vs. SC, then that's the only justification you need to do it first in an emergency.

But just out of curiosity, why?

Incidentally, if you go just two fingers up and two to the side heading toe-ward, there's a good chance you did a supraclavicular SC a fair few times! 😉

I have yet to do one in an actual emergency due to the fact that we cannot do them in the counties I interned in and worked in. I liked the IJ because (also why I like EJ) of the fact that I could remain at the head and gain access and then go to maintaining the airway, it just seemed natural.

 

[EMS5]

Ultimate solution: open thoracotomy, put the biggest tube you can find in the biggest vein you can find, pump full until eyes leak saline... Somehow they forgot that in atls

On a more serious note, IO is the way to go for me! Since we got Ez Io drills I have no desire to go jabbing at an ej. Besides, no one else except surgeons get to take to their patients with a dremel tool!

 

[old_boy]

As a junior resident I found this discussion very interesting - thank you for those who shared your viewpoints.

As an aside, at our program cut-downs aren't taught and subclavians are very attending dependent and few and far between (which is depressing as it's a procedure I would like to become facile with, which seems unlikely). This pt would probably get a tibial IO followed by an ij or fem line. I'm intrigued by the humeral IO and will be trying this.