Vascular

  • Arterial Line Insertion
  • Central Venous Access
  • Intraosseous Access
  • Peripheral Intravenous Access
  • Ultrasound-Guided Peripheral Vascular Access

Arterial Line Insertion

  • Background
    • Placement of a catheter into the lumen of an artery (typically radial or femoral) for the purposes of providing continuous display of blood pressure and frequent access to arterial blood sampling.
  • Indications
    • Titration of vasopressors, need for recurrent ABG sampling, need for continuous and more accurate BP measurement. 
  • Contraindications
    • Infection over insertion site, absent pulse, vascular injury proximal to placement
  • Complications
    • temporary radial artery occlusion (19.7%), hematoma (14.4%), infection (0.72%)
Video Credit: EM:RAP

*Deep Dive: Under Pressure: Arterial Lines in the Emergency Department (emDocs)



Central Venous Access

  • Background
    • Placement of a large catheter into a central venous access site, typically the internal jugular, femoral, or subclavian vein. Favored over peripheral IVs in terms of longevity, site security, and ability to rapidly administer fluids and multiple medications.
  • Indications
    • Volume resuscitation, administration of caustic medications or vasopressors, inability to obtain peripheral access, need for multiple medications/drips.
  • Contraindications
    • Anatomic obstruction, infection over placement site. Relative contraindications include bleeding disorder or uncooperative patient.
  • Complications
    • Arterial puncture (common with femoral), pneumothorax (common with subclavian), infection, arrhythmia (from guidewire insertion)
Video Credit: Behind the Knife

*Deep Dive: Never Let Go -A Review of Central Venous Access Placement (emDocs)



Intraosseous Access

  • Background
    • Placement of a hollow-bore needle through the cortex of a bone into the medullary space, allowing for a useful alternative to IV access. Common sites include the proximal tibia, distal tibia, proximal humerus, sternum, and distal femur.
  • Indications
    • Need for immediate venous access when traditional IVs fail. Commonly performed cardiac arrest.
  • Contraindications
    • Osteoporosis, overlying infection, recent attempt on the same bone, fracture
  • Complications
    • Fracture, incomplete penetration, infection
Video Credit: EM:RAP

*Deep Dive: Feelin’ It in my Bones: A Review of Intraosseous Access in the Emergency Department (emDocs)



Peripheral IV Access

  • Background
    • Placement of a cannula (typically 16-24 gauge) inside a peripheral vein, allowing venous access for medications, fluids, and diagnostic blood testing.
  • Indications
    • Repeated blood sampling, administration of mediations, fluids, blood products.
  • Contraindications
    • No absolute contraindications. Avoid placing IV’s in burned, infected, or injured areas.
  • Complications
    • Failure to access vein, extravasation, thrombophlebitis, arterial puncture. 
Video Credit: Core EM

*Deep Dive: How To Do Peripheral Vein Cannulation (Merck Manual)



Ultrasound-Guided Peripheral Vascular Access

  • Background
    • Placement of peripheral IV under the guidance of point-of-care ultrasound. Allows for visualization and guidance to cannulate deeper vessels, particularly in patients who are known to have difficult veins. 
  • Indications
    • Typically used after multiple palpation-based attempts have failed
  • Contraindications
    • Infection overlying insertion site, vascular injury proximal to site.
  • Complications
    • Failure to place IV, hematoma, arterial puncture, nerve damage.
Video Credit: Core Ultrasound

*Deep Dive: Techniques for Ultrasound-Guided IV Placement (ALiEM)


Brandon Simpson, PA-S2
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