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

• Ultrasound has been shown to greatly increase first pass success. Consider making this your standard practice.
• Check for collateral circulation prior to insertion. You can perform the Allen Test or evaluate flow utilizing Doppler.

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

• Never lose control of your guidewire. You don’t want to lose it inside the patient’s vein!
• Avoid using the internal jugular site in patients with elevated intracranial pressure (ICP), as this may worsen cerebrovascular compliance.

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

• This technique has been shown to be safe and efffective, though has not yet been adopted widespread as common practice. Be sure to communicate your reasoning to specialists and admitting teams.
• The Easy IJ is only intended for 24 hours of use, but some studies suggest that they may be left in up to 7 days. 

Deep Dive

• More on the Easy IJ (REBEL EM)

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

• The distal tibia is typically easier to identify and place, though the proximal humerous route achieves significantly higher infusion rates.
• If using the proximal humorous, the arm must stay immobilized in an adducted position. Abduction will cause displacement of the IO.

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

• The ideal vein is the one that feels the best, not necessarily visualized the best.
• Smaller gauge catheters (20-22g) are appropriate for non-emergent calls or elderly patients with fragile veins. Larger gauge catheters (14g-18g) are necessary for trauma patients or those receiving emergent medications.

Deep Dive

• How To Do Peripheral Vein Cannulation (Merck Manual)

Rapid Review

• Background
  • Resuscitative Endovascular Balloon Occlusion (REBOA) involves the insertion of a balloon catheter through the femoral artery and into the aorta to allow for hemorrhage control in the abdominal or pelvic regions.
• Indications
  • Hemodynamic instability or PEA arrest (within 10 minutes) due to abdominal or pelvic hemorrhage
• Contraindications
  • Age < 18 or > 70
  • Aortic dissection, cardiac tamponade, atraumatic cardiac arrest
• Complications
  •  Embolization, peripheral ischemia, vessel injuries (aortic dissection/perforation)

Pearls

• Although mortality benefit has not been definitively demonstrated yet, REBOA provides a useful, less-invasive, alternative to resuscitative thoracotomy.
• The balloon should be inflated in Zone 1 (subclavian artery to celiac trunk) if patient has non-compressable abdominal hemorrhage, and Zone 3 (lowest renal artery to aortic bifurcation) if patient has signficant pelvic injury or extremity bleeding. Zone 2 (celiac trunk to lowest renal artery) has limited value and should be avoided.

Deep Dive

• REBOA (NUEM Blog)

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

• The basilic vein in the upper arm is an ideal choice for ultrasound-guided IVs.
• If you are having difficulty identifying the tip of the needle with your ultrasound, try tilting the probe slightly away from yourself. 

Deep Dive

• Techniques for Ultrasound-Guided IV Placement (ALiEM)

Rapid Review

• Background
  • Cannulation of the umbilical vein in neonates requiring vascular access and resuscitation.
  • The umbilical vein remains patient and viable central venous access for approximately 7-14 days after birth
• Indications
  • Need for vascular access when peripheral access is unobtainable
• Contraindications
  • Omphalitis, omphalocele, peritonitis, gastroschisis, necrotizing enterocolitis
• Complications
  • Similar to other forms of central line access (hemorrhage, infection, air embolism, arterial placement)

Pearls

• The umbilical cord will have two arteries and one vein, making a sort of “smiley face”. Your target is the mouth!
• When removing the catheter, be sure to tighten the tape or suture to avoid an air embolism.

Deep Dive

• Procedure: Umbilical Vein Catheterization (First10EM)