By: Dan Resnick-Ault, M.D.
At Boston City EM, tradition is alive and well in the resuscitation bays, where obtaining vascular access is delegated to a PGY-1 or 2 while an emergency medicine (EM) senior resident ‘runs’ the case (supervised by an EM attending of course). In medical cases, the EM intern is responsible for placing IVs. In patients suffering blunt or penetrating trauma, the procedure resident, an EM PGY-2, obtains access. In either situation, our experienced ED nurses will either simultaneously search for a vein on the opposite arm or provide guidance if the resident is struggling.
Because of the baseline characteristics of patients presenting to our resuscitation bays, obtaining access can be quite challenging. Our medical resuscitation patients in particular have the tendency to be chronically ill, intravascularly depleted, or long-standing intravenous drug users. Below is my general approach to obtaining access in patients presenting to resus, which is graded depending on severity of illness.
The 96%: Peripheral IV first
The majority of patients arriving to the resuscitation room require intravenous access for an initial lab draw and delivery of medications. In the “metastable” patient, a delay of minutes is unlikely to impact their ultimate trajectory, so it is worthwhile to search for a peripheral vein, even if a delay is incurred. My personal preference is to reach for an 18-gauge catheter first. Although most junior providers associate using a smaller catheter with a higher probability of success, this isn’t necessarily the case with all patients and smaller catheters are more difficult to both draw blood and deliver medication or fluid boluses through. Importantly, being accustomed to placing large peripheral IVs becomes paramount when confronted with trauma or medically hemorrhaging patients who might initially appear stable but can deteriorate and require massive transfusion on the way to the operating room.
When the AC, forearm, and hands are without veins to cannulate:
The external jugular (EJ) is the first place to look. These veins are often prominent, and even morbidly obese patients can surprise you with a plump EJ that appears at the neck fold when the patient is supine or in Trendelenburg. Because the EJ can be quite mobile under the skin, it is important to anchor the vessel distally. If the patient is alert and not in respiratory distress, having them Valsalva will often fill the jugular venous system and facilitate cannulation. An added benefit is that external jugular veins are almost always large enough to accept a 16-gauge catheter if needed for aggressive volume resuscitation. The EJ affords fast vascular access that is proximal to the heart and is often reliable even in patients whose arm veins have been exhausted through repeated venipuncture. The skin of the neck can be quite thick, so outside of the resus bay consider employing lidocaine if time permits. In those with really thick skin, a tiny ‘nick’ with an 11 blade can facilitate smooth catheter passage and greater control of your 16 or 18 G catheter (where otherwise it might ‘catch’ on the skin, indenting as you advance, recoiling as you relax). Keep in mind your institution may not allow administration of intravenous contrast through an EJ.
At our institution we rely heavily on deep brachial access under ultrasound guidance in the ED. It is important to be facile with this technique, but there are a handful of disadvantages. Chiefly, even with the routine use of specialized, long catheters, these lines have a tendency to displace and extravasate. Because of the depth of the vessels that are typically accessed, extravasation can be difficult to distinguish even for experienced nurses. This makes them suboptimal for peripheral vasopressors, but also for patients receiving IV medications whose disposition is admission to the floor, where the patient to nurse burden might prevent timely identification of IV failure. Two promising future directions are the placement of commercially available midlines (essentially an even longer catheter introduced over a wire) and the ultrasound-guided cannulation of the internal jugular with a long peripheral catheter.
IO first, ask questions later.
Patients requiring fast intervention deserve fast, reliable access. Status epilepticus, shock and hypotension, cardiac arrest, and severe respiratory distress requiring emergent intubation are just some of the conditions that should prompt residents to reach for the EZ-IO ® driver. The proximal humeral site paired with a bariatric needle has an excellent success rate, and access can be reliably obtained in 90 seconds. (PMID: 18619171, PMID: 19741408) There is typically pain associated with infusion in conscious patients, though this can be somewhat mitigated by pre-filling the extension set with lidocaine and slowly instilling 60 mg of 2% lidocaine (3 mLs from the “code-dose” lidocaine pre-filled syringe) In a shocked patient who is mentating poorly, the adrenergic surge provoked by IO infusion is not necessarily unwelcome. If the IO does not flow well, a brisk, forceful flush of 10-20 mLs of saline can usually hollow out the marrow space enough to allow free flow. Fluids, vasopressors, rapid sequence induction medications, and blood products can all be administered through the IO. With access secured, a search for a peripheral vein can be undertaken once the patient is stabilized or a central venous catheter can be placed.
Central Venous Line
While the advantages of the central line are limited in terms of resuscitation in the ED—most medications can safely be administered peripherally and flow rates through large bore IVs exceed those through most central lines—the CVC plays an important role in the ICU. Patients being transferred to the unit who are hemodynamically unstable, on vasopressors, have tenuous IV access, or have significant metabolic abnormalities requiring frequent lab draws all deserve central access in the ED. In patients who require massive transfusion protocol, if large bore peripherals cannot rapidly be obtained, a subclavian sheath introducer is often the preferred access. Femoral vein cannulation is avoided in patients who have suffered blunt or penetrating trauma to the pelvis or abdomen for fear that infused blood will seep from damaged veins without seeing the central circulation. Despite the advent of a number of means of gaining peripheral access and a growing reluctance to the placement of central lines due to CLABSI risk, a subset of patients will simply have to have a central line placed due to poor peripheral access, and EM residents grow quite facile with CVC placement during residency.
EM residents at our institution have a number of tools at their disposal to obtain vascular access in sick patients. As important as the procedural skill and familiarity with each of these methods is the ability to maintain situational awareness, recognize when critically ill patients require immediate access, and identify when a particular method has failed and a secondary approach should be used.
Resident Author: Dan Resnick-Ault, MD
Faculty Review: William Baker, MD