![]() This article will focus on the placement of CVCs including indications, contraindications, site choice, and complications. The methodology has evolved over the past several decades and is now performed with or without ultrasound guidance, both of which techniques we will discuss below. The Seldinger technique is the foundation of most intravascular procedures and can be utilized for both peripheral and central venous catheters. Central venous access is obtained via the readily utilized Seldinger technique, in which a catheter is placed over a guidewire that has been threaded into a vessel through an introducer needle. A CVC is actually defined as a catheter whose tip resides within the superior vena cava, inferior vena cava, or at the junction between the vena cava and the right atrium (cavoatrial junction). While the location of insertion is vital in certain scenarios, it does not define a CVC. While most patients in the ED will simply require peripheral IV access, the vignettes above present two critically-ill patients in very different circumstances, both of whom will likely require central venous catheter (CVC) placement. The ability to obtain rapid IV access in any patient, regardless of the clinical scenario, is a quintessential skill practiced by emergency physicians. What is your next step? Will you pursue venous access through an ultrasound guided peripheral IV? Is this patient suitable for an IO? Is this a time to go straight to central venous access? If so, which location and why? As you rapidly run through ATLS in your head and organize the order of interventions necessary, the RN affirms she cannot get intravenous access on this patient. Paramedics were only able to obtain intravenous access via a 22g IV in the right hand. On secondary survey, the patient has obvious signs of blunt thoracic, abdominal, and pelvic trauma in addition to a right sided open femur fracture. Initial vitals include BP 80/40, HR 130, RR 30, and O2 Sat 91% on non-rebreather. She presents awake, alert, and in severe painful and respiratory distress. Is there a particular site safer than others? Might one site have a lesser chance of infection over another? What if the ultrasound is in the shop for service over the holiday weekend?Ī 22-year-old female with no past medical history presents to the ED via EMS after being struck while riding an electric scooter by a vehicle going approximately 30 mph. While the peripheral norepinephrine drip is started, you begin to consider the ideal location of central venous access in this patient. You request the nurse to start norepinephrine and are quickly reminded that as per hospital policy, peripheral vasopressors may only be utilized as a temporizing measure while definitive central venous access is obtained. ![]() ![]() After evaluating the patient and providing an intravenous (IV) fluid bolus, the patient remains hypotensive, tachycardic, tachypneic, hypoxic, and febrile. A nurse tells you the patient has become hypotensive and more confused. Print them out and be ready to go over it with your learners!Ī 55-year-old female with a past medical history of hypertension and diabetes was admitted for pneumonia 10 hours ago and is currently boarding in the Emergency Department (ED) whilst awaiting a telemetry bed. Welcome back to Unlocking Common ED Procedures! Today, we focus on central venous lines in the ED.Ĭheck out our new downloadable procedure card with QR code link to the article. Author: Anthony DeVivo, DO ( EM-Critical Care Fellow, Icahn School of Medicine- Mount Sinai Hospital) // Reviewed by: Alex Koyfman, MD ( Brit Long, MD ( and Manpreet Singh, MD ( ) ![]()
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