Vascular

Rapid Review

• 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%)

Pearls

Deep Dive

• Under Pressure: Arterial Lines in the Emergency Department (emDocs)

Rapid Review

• 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)

Pearls

Deep Dive

• Never Let Go -A Review of Central Venous Access Placement (emDocs)

Rapid Review

• Background
  • The easy internal jugular (“Easy IJ”) technique involves placement of a single-lumen peripheral IV catheter into the internal jugular using ultrasound guidance. This is placed in a limited sterile environment.
• Indications
  • Patients with difficult peripheral access, failing ultrasound guided peripheral IV placement
• Contraindications
  • Overlying skin infection, thrombosis of internal jugular vein
  • Do NOT place an Easy IJ in patients who require central venous access. 
• Complications
  • Few complications documented. May be susceptible to dislodgement.

Pearls

Deep Dive

Rapid Review

• 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

Pearls

Deep Dive

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

Rapid Review

• 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. 

Pearls

Deep Dive

• How To Do Peripheral Vein Cannulation (Merck Manual)

Rapid Review

Pearls

Deep Dive

Rapid Review

• 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.

Pearls

Deep Dive

• Techniques for Ultrasound-Guided IV Placement (ALiEM)

Rapid Review

Pearls

Deep Dive