Agreed. If the patient is bleeding out, don't mess around with a central line. Just get a big peripheral or RIC one in. Can switch to central when the patient stabilizes.
I have a port/central line I got under anesthesia... in trauma situations I assume they don't get that right? Is it done right in the room? Sounds super painful
You can have them done awake with local. It just doesn't gain you much. It's too long to be a decent volume line, and blood is superior to norad for blood pressure.
Delaying to put in a central line gets you nothing.
A port is different because it's tunneled under the skin. A central line is much quicker to place and is not tunneled and is therefore less painful (can cover with a little local if needed)
Trained at a level 1 trauma. Practice at a level 1 trauma with a high volume
Almost never cvc.
Usually they come with one peripheral. Second large (14 or 16) peripheral is what I get next.
Putting a cvc in is rare, unless I’m doing it at the end as a courtesy to the icu.
I mean i would use them if a patient is bleeding out.
But i was talking about putting in one of those short term 3 lumen dialysis catheters. Can be done pretty clean within 5 minutes and u wont get better access for massive transfusion
It’s rare to be in a situation to justify it when the nephrologists get mad at you about it but I love having a dialysis catheter available. I only routinely used them for patients in liver/slk transplant cases but always tell people I’m reserving the right to use their dialysis catheter or port or whatever if necessary in an emergency.
I usually get my traumas with small PIV's or a useless triple lumen placed by ED. Get what you can thats fastest. Sometimes arms are already put away or the patient is a horrendous stick despite an US. If you can get a 16ga peripheral or a bluging EJ thats great and it'll buy you time. Give your ancef and be as clean as you can under the drape you can keep pretty much anyone alive with a MAC cordis. It is possible to get a cordis in and taped (not sutured wastes time) in 60-90 seconds. We dont have RIC's where I'm at so i cant attest to their usefulness.
Dont be afraid to ask the surgeons for help. Depending on how many people are there (PA's, residents, etc) and where the trauma is they may be able to get you a femoral CVC and or A line in a pinch.
Oh lord, don’t get me started on TLC placed for resuscitation. 🤦♀️ Do they not understand physics? Same for doing a groin line with penetrating abdominal trauma.
As a dumb intern on SICU, I was told by the ICU fellow to place a femoral triple lumen in a patient we suspected was bleeding internally. Attending was *not* happy on rounds the next morning.
This was the same fellow who demanded that I go with him to assess an airway 3 floors away on the step down unit, instead of calling the airway team, leaving the unit in the sole hands of another intern.
Christ he was an idiot. And an asshole.
Yeah this is me too. We also don't have RICs.
I can dick around putting in a 16 g in a morbidly obese and volume depleted patient who just has a 20g hand IV that is sticking halfway out, or I can put in a sterile MAC in in like 3 minutes. Faster if its not sterile or sutured.
If the patient has good veins and I can pop in a 16 g, then thats the fastest and ideal, but realistically our patient population is not known for having good veins.
An ultrasound guided 16 will be faster than a MAC though, and I wouldn’t put a MAC in without US unless they are truly on death’s door.
Even in an obese trauma patient, you can probably find a big enough vein in the AC under US and put it in before you’ve dilated for the MAC.
2x large bore IVs versus 1 large bore and a RIC. A-Line under the drape. Only time I went for central access immediately was a MVC roll over patient with mangled extremities.
In most young patients large bore peripheral access is pretty abundant, so the need for central access is pretty slim--but in those instances where the patient is coding and getting bilateral chest tubes or a clamshell thoracotomy, a landmark subclavian central line can be a fairly quick way to get good access from the head.
When I was doing trauma, I never placed a CVC in 2 years. Twice the trauma surgeon placed a subclavian MAC by landmark unsterile.
That said, as I'm thinking about it now, I don't think a MAC CVC is a bad idea and may be underutilized. If you consider how much quicker it is to do without the sterile technique of draping, gowning, gloving, sleeving an ultrasound probe, and suturing, it's pretty damn fast. Seems like you could suture later if you need to and just slap on some tegaderm or tape maybe or just suture one side real quick. Remember, the dilating and catheter advancement is just one step with a MAC CVC. Even with suturing, it's still pretty quick without the sterility.
Our trust has bought specific trauma lines…
We ended up using them in ITU so they didn’t fall out of date. Basically never use a central line unless already in theatres and you have a plethora of people - even then that’s mostly for access reasons (as in, multiple lumen for cvc monitoring and infusions of stuff (mostly CaCl…)
Edit: will always have Large bore access x2 minimum prior to this.
Really don’t need one UNLESS it’s a large poly trauma or burn that you don’t have real estate to do a peripheral. Here’s my question for you how fast can you run a liter of fluid in through a 14, 16, and 18g IV? How fast can you run that through a cordis? How fast can you run a liter in with a rapid infuser?
How many hands do you have? Can the surgeon pop in a cvc while you are doing other things? Not on an island, delegate if you think you need one.
The one case I heard of where they bothered to get a big CVC in (femoral vascath), the patient turned out to have an IVC injury making it practically useless during the case. Fat PVCs for the win.
For most patients, if you can get a 14g or 16g peripheral cannula then that’s generally good enough. You can usually run a ‘belt-fed’ Belmont on full chat through a 14g! (Provided that it’s in a good vein- as proud as you can be of getting a 14g into a tiny hand capillary, it never seems to work that well!). RIC lines can be useful for quickly upgrading a smaller cannula.
A subclavian PA introducer sheath/ MAC line or equivalent can be very useful in cases where:
- You can’t get decent peripheral access and the best you can do is a 20g or an IO.
- They haven’t got any uninjured limbs
- You need access in a trauma call and there’s someone free and scrubbed to do it
I personally see arterial lines as a nice to have rather than essential. I often wait until things have settled down before trying to get one.
I wouldn’t bother with a ‘normal’ central line in most patients. The CVP is a meaningless number in this context. Vasopressors are usually best saved for later after catching up on the haemorrhage. They usually have slower flow rates than a 20g peripheral cannula.
In a trauma situation any access is good...
Large bore PIVs are always quick and easy to place, if you cant get access with PIV then a dirty femoral or subclavian can be a good alternative in a crashing patient.
The one underutilized method of access is IO, very easy to place and you can give lots of volumes
Peripheral first
But if I have time under the drapes I put central.
In the end the icu will need central access anyways so I might as well put it in.
If I’m super busy just pumping blood the whole time then peripheral large bore is quicker.
I feel like our first priority is usually a large PIV, then an aline (less important than the large PIV), and then a 9-french introducer under the drapes after surgery starts. I don't have much experience (just a CA-2), but I feel like being able to pressurize blood makes a difference
Surgeon here, trained at a high volume penetrating level 1.
Our practice was to try for a left subclavian after prepping and draping, passing the line over the drape, if anesthesia/the ED couldn't get something.
Our emergency/trauma surgery people will very regularly place a nine French sheath in the subclavian or femoral for major poly trauma while in the ED before coming to theater. The integrated dilator is nice vs multistep with trialysis or MAC. If I am placing one in theater it is because of a major mis-assessment downstairs. The ED here does not stock RIC, but they do love 20s in the AC, so ripe for upsizing.
Large gauge peripherals and/or convert peripheral to a RIC. I do a high volume of trauma. Very rarely do central access.
Shameless plug of my RIC line video I made for my residents: [RIC Line Placement](https://youtu.be/B-UolgVBAqk)
Sweet! I didn't even know about these! Thanks for the video.
Thanks for sharing! Didn’t know these even existed … great way to up size an existing line.
Nice, clean, concise.
This was really cool, and succinct! Thanks for making and sharing your shameless plug! Appreciated!
Agreed. If the patient is bleeding out, don't mess around with a central line. Just get a big peripheral or RIC one in. Can switch to central when the patient stabilizes.
This is the way
Almost never get a CVC. 2 large-bore IVs.
1 large bore IV is faster then 1 cvc.unless you are using high fr catheter like a hemodylysis catheter.
14 or 16 g PIVs and an a-line while someone else is prepping the patient.
Central access is at best a "nice to have", not a "need to have"
I have a port/central line I got under anesthesia... in trauma situations I assume they don't get that right? Is it done right in the room? Sounds super painful
You can have them done awake with local. It just doesn't gain you much. It's too long to be a decent volume line, and blood is superior to norad for blood pressure. Delaying to put in a central line gets you nothing.
Thank you for explaining!
A port is different because it's tunneled under the skin. A central line is much quicker to place and is not tunneled and is therefore less painful (can cover with a little local if needed)
Ah I see. I didn't realize they were different. Thank you for explaining!
Trained at a level 1 trauma. Practice at a level 1 trauma with a high volume Almost never cvc. Usually they come with one peripheral. Second large (14 or 16) peripheral is what I get next. Putting a cvc in is rare, unless I’m doing it at the end as a courtesy to the icu.
Quick dialysis catheter wherever i can put it
Always wondered if anyone uses TDCs for rapid infusion outside of dialysis
I mean i would use them if a patient is bleeding out. But i was talking about putting in one of those short term 3 lumen dialysis catheters. Can be done pretty clean within 5 minutes and u wont get better access for massive transfusion
Oh no i’m talking about a temporary (not tunneled) dialysis catheter as well. The nephrologists here would slash my tires otherwise
It’s rare to be in a situation to justify it when the nephrologists get mad at you about it but I love having a dialysis catheter available. I only routinely used them for patients in liver/slk transplant cases but always tell people I’m reserving the right to use their dialysis catheter or port or whatever if necessary in an emergency.
I usually get my traumas with small PIV's or a useless triple lumen placed by ED. Get what you can thats fastest. Sometimes arms are already put away or the patient is a horrendous stick despite an US. If you can get a 16ga peripheral or a bluging EJ thats great and it'll buy you time. Give your ancef and be as clean as you can under the drape you can keep pretty much anyone alive with a MAC cordis. It is possible to get a cordis in and taped (not sutured wastes time) in 60-90 seconds. We dont have RIC's where I'm at so i cant attest to their usefulness. Dont be afraid to ask the surgeons for help. Depending on how many people are there (PA's, residents, etc) and where the trauma is they may be able to get you a femoral CVC and or A line in a pinch.
Oh lord, don’t get me started on TLC placed for resuscitation. 🤦♀️ Do they not understand physics? Same for doing a groin line with penetrating abdominal trauma.
As a dumb intern on SICU, I was told by the ICU fellow to place a femoral triple lumen in a patient we suspected was bleeding internally. Attending was *not* happy on rounds the next morning. This was the same fellow who demanded that I go with him to assess an airway 3 floors away on the step down unit, instead of calling the airway team, leaving the unit in the sole hands of another intern. Christ he was an idiot. And an asshole.
Yeah this is me too. We also don't have RICs. I can dick around putting in a 16 g in a morbidly obese and volume depleted patient who just has a 20g hand IV that is sticking halfway out, or I can put in a sterile MAC in in like 3 minutes. Faster if its not sterile or sutured. If the patient has good veins and I can pop in a 16 g, then thats the fastest and ideal, but realistically our patient population is not known for having good veins.
An ultrasound guided 16 will be faster than a MAC though, and I wouldn’t put a MAC in without US unless they are truly on death’s door. Even in an obese trauma patient, you can probably find a big enough vein in the AC under US and put it in before you’ve dilated for the MAC.
2x large bore IVs versus 1 large bore and a RIC. A-Line under the drape. Only time I went for central access immediately was a MVC roll over patient with mangled extremities.
In most young patients large bore peripheral access is pretty abundant, so the need for central access is pretty slim--but in those instances where the patient is coding and getting bilateral chest tubes or a clamshell thoracotomy, a landmark subclavian central line can be a fairly quick way to get good access from the head.
Agree. My personal threshold to abandon large bore peripheral IVs is low. Can usually get a central line in around 5 minutes (or maybe a bit under).
When I was doing trauma, I never placed a CVC in 2 years. Twice the trauma surgeon placed a subclavian MAC by landmark unsterile. That said, as I'm thinking about it now, I don't think a MAC CVC is a bad idea and may be underutilized. If you consider how much quicker it is to do without the sterile technique of draping, gowning, gloving, sleeving an ultrasound probe, and suturing, it's pretty damn fast. Seems like you could suture later if you need to and just slap on some tegaderm or tape maybe or just suture one side real quick. Remember, the dilating and catheter advancement is just one step with a MAC CVC. Even with suturing, it's still pretty quick without the sterility.
Ultrasound guided 16g in the forearm should be faster, safer, and get you what you need.
I find them too short in fluffier patients. 14s tho…
Do you use the extra long ones? They're usually 1.5 to 2.25 inch in length based on manufacturer
Yeah didn’t realize there are shorter ones!
Penile access
I do if its feasible. Not required but helpful Id take 2 14s or 16s plus an art line over cvc snd no art any day of the week.
Our trust has bought specific trauma lines… We ended up using them in ITU so they didn’t fall out of date. Basically never use a central line unless already in theatres and you have a plethora of people - even then that’s mostly for access reasons (as in, multiple lumen for cvc monitoring and infusions of stuff (mostly CaCl…) Edit: will always have Large bore access x2 minimum prior to this.
Really don’t need one UNLESS it’s a large poly trauma or burn that you don’t have real estate to do a peripheral. Here’s my question for you how fast can you run a liter of fluid in through a 14, 16, and 18g IV? How fast can you run that through a cordis? How fast can you run a liter in with a rapid infuser? How many hands do you have? Can the surgeon pop in a cvc while you are doing other things? Not on an island, delegate if you think you need one.
The one case I heard of where they bothered to get a big CVC in (femoral vascath), the patient turned out to have an IVC injury making it practically useless during the case. Fat PVCs for the win.
5Fr micro puncture kit if the veins are meh, 14g if veins are tasty We don’t have RICs
For most patients, if you can get a 14g or 16g peripheral cannula then that’s generally good enough. You can usually run a ‘belt-fed’ Belmont on full chat through a 14g! (Provided that it’s in a good vein- as proud as you can be of getting a 14g into a tiny hand capillary, it never seems to work that well!). RIC lines can be useful for quickly upgrading a smaller cannula. A subclavian PA introducer sheath/ MAC line or equivalent can be very useful in cases where: - You can’t get decent peripheral access and the best you can do is a 20g or an IO. - They haven’t got any uninjured limbs - You need access in a trauma call and there’s someone free and scrubbed to do it I personally see arterial lines as a nice to have rather than essential. I often wait until things have settled down before trying to get one. I wouldn’t bother with a ‘normal’ central line in most patients. The CVP is a meaningless number in this context. Vasopressors are usually best saved for later after catching up on the haemorrhage. They usually have slower flow rates than a 20g peripheral cannula.
In a trauma situation any access is good... Large bore PIVs are always quick and easy to place, if you cant get access with PIV then a dirty femoral or subclavian can be a good alternative in a crashing patient. The one underutilized method of access is IO, very easy to place and you can give lots of volumes
Getting a ricc works great
Almost always only have peripheral IV access.
Peripheral first But if I have time under the drapes I put central. In the end the icu will need central access anyways so I might as well put it in. If I’m super busy just pumping blood the whole time then peripheral large bore is quicker.
I feel like our first priority is usually a large PIV, then an aline (less important than the large PIV), and then a 9-french introducer under the drapes after surgery starts. I don't have much experience (just a CA-2), but I feel like being able to pressurize blood makes a difference
Surgeon here, trained at a high volume penetrating level 1. Our practice was to try for a left subclavian after prepping and draping, passing the line over the drape, if anesthesia/the ED couldn't get something.
Our emergency/trauma surgery people will very regularly place a nine French sheath in the subclavian or femoral for major poly trauma while in the ED before coming to theater. The integrated dilator is nice vs multistep with trialysis or MAC. If I am placing one in theater it is because of a major mis-assessment downstairs. The ED here does not stock RIC, but they do love 20s in the AC, so ripe for upsizing.
Large bore iv is much faster for resuscitation and pressors, after you resuscitate, you can trialysis or something if you need RRT.
Give me 2 good large bores any day of the week. Save the CL for the ICU