Jason Rogers MSN, NP, NREMT-P, FNP-BC, ACNP-BC CCEMT-P, FP-C, C-NPT, CFRN, CTRN Emergency Nurse Practitioner Flight Paramedic/Nurse

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1 Jason Rogers MSN, NP, NREMT-P, FNP-BC, ACNP-BC CCEMT-P, FP-C, C-NPT, CFRN, CTRN Emergency Nurse Practitioner Flight Paramedic/Nurse

2 Objectives Identify the role of Central Venous Access and Arterial Line Monitoring In the Emergency Department and Critical Care Identify the appropriate sites and land marks for central venous line and arterial line placement Discuss the risk and complications associated with central venous and arterial line placement Provide examples of patient conditions that necessitate central venous access and or arterial line placement and monitoring

3 Objectives Identify practical methods in verifying central line placement Summary

4 Uh Oh Where Did That Line Go? What does it mean to monitor? Latin term monere To remind or advise Ultimate Goal of Invasive Monitoring Treat and prevent organ dysfunction and cellular injury Early Goal Directed Therapy in the ED

5 Uh Oh Where Did That Line Go? Role of CV access in resuscitation CVC allows for multiple critical actions to be performed in the emergency department.

6 Uh Oh Where Did That Line Go? Role of CV access in resuscitation Administration of fluids and blood products Administration of vasoactive drugs Transvenous cardiac pacing Hemodynamic monitoring. Multiple points of circulatory access

7 Uh Oh Where Did That Line Go? Contraindications to CV placement Severe coagulopathy Obstruction or congenital abnormality Patient refusal (if competent) Restless and uncooperative patient, unless sedation can be utilized Lack of experience and no expert supervision, OR previous failed attempt by experienced physician Injury or infection at the site

8 Uh Oh Where Did That Line Go? Complications More than 15% of all central lines have a complication Mechanical 5-19% Infectious 5-26% Thrombotic 2-26%

9 Uh Oh Where Did That Line Go? Complications

10 Pneumothorax More common in subclavian Incidence ranges from 0.3 to 3% depending on experience Classic presentation = hypoxemia/hypotension/pleuritic CP Can be treated conservatively in nonventilated patients

11 Sinistro is Sinister Left internal jugular has unique complications thoracic duct injury Left inominate vein can be lacerated hemothorax and OR L IJ or SC catheter too proximal can lacerate SVC death

12 Left Subclavian Artery

13 Uh Oh Where Did That Line Go?

14 UltraSound Prevention is always better than treatment Use ultrasound probe to localize vessel Cannulate vessel under direct vision

15 Verifying Placement Several options: Connect sterile tubing to pressure tubing and flush Attach to needle in vessel and confirm venous trace Remove syringe and confirm non-pulsatile blood Compare arterial blood sample with your sample

16 EMCrit Method Are you in the Artery or the Vein?

17 Landmarks for IJ insertion

18 IJ Insertion Method After flash of blood, syringe is removed and a guidewire is advanced to 20cm The needle is then removed, leaving the guidewire in place

19 IJ Insertion Method Position of guidewire in relation to neck anatomy Make a small skin stab at wire insertion site. Note control of guidewire with both hands

20 Insertion Method-Subclavian Most use infraclavicular approach (insert at fossa of deltopectoral groove, about 1-2 cm inferior to clavicle) Poor choice in coagulopathy (difficult to compress) Higher PTX risk than internal jugular (1-5%) Less infection risk than IJ Trendelenburg s position with towel roll under scapulae Direct needle toward sternal notch Keep needle parallel to floor; DO NOT AIM UNDER CLAVICLE OR YOU WILL CAUSE PNEUMOTHORAX Constant suction in and out Ultrasound not as useful Again, think after inserting needle 5 cm deep

21 Landmarks for SubClavian Insertion

22 Landmarks for Femoral Insertion Vein is medial to femoral artery In anatomic position (legs apart), axis of vein is as pictured: toward umbilicus Note the inguinal ligament!

23 Perils of Line Placement General Prinicipals Sterile technique is extremely important Check radiograph for any existing pathology (put line on the same side as pathology) Check coagulation studies, if indicated Position patient appropriately Ensure correct position and check radiograph to evaluate for complications Three poke rule (get another person to do procedure)

24 The line is in. Now what?

25 Now, is anything wrong?

26

27 ETT in too far

28 Chest tube in poor position

29 Left mainstem intubation

30 Feeding tube in lung Feeding tube in lung

31 Subclavian going In wrong direction

32 Carotid Artery Insertion

33 ETT Hematoma After Subclavian Artery Puncture NG

34 NG Tube in left lung.

35 Subclavian Crossing Through innominate

36 What is right with this picture?

37 Uh Oh Where Did That Line Go? Role of Arterial Line Insertion and Monitoring Arterial line monitoring is a crucial part of the care of the critically ill patient in the emergency department as the physiological response to critical illness is linked strongly to outcome. Critically ill or injured patients frequently have profound abnormalities in their blood pressure. The arterial line provides a way to constantly measure a patient's blood pressure and may be essential to the stabilization of the patient.

38 Uh Oh Where Did That Line Go? Role of Arterial Line Insertion and Monitoring System designed for continuous measurement of: Systole, Diastole and Mean Arterial Pressure Also allows direct access for blood draws for ABGs and/or other frequent tests.

39 Uh Oh Where Did That Line Go? Role of Arterial Line Insertion and Monitoring Insertion Most frequent insertion site = Radial Alternate Sites femoral Dorsalis Pedis Brachial Axillary

40 Uh Oh Where Did That Line Go? Role of Arterial Line Insertion and Monitoring MAP most often used to assess perfusion. Represents perfusion pressure throughout the cardiac cycle. Need a minimum MAP of 60 mm Hg to perfuse vital organs. Requirements will depend upon Diagnosis. May need to increase CPP in carotid or neurologic surgery may be ideal for the cardiac patient to decrease LV workload

41 Arterial vs Cuff Pressures Arterial vs Cuff Pressures Arterial catheters = direct measurement and are MORE ACCURATE especially in shock, severe hypotension, vasoconstriction and obesity. Radial catheters will usually show a pressure slightly higher (about 10 mmhg) than cuff. MAP tends to be the same and is a better reflection of perfusion pressure.

42

43 Uh Oh Where Did That Line Go? Maintaining the Line Care is directed to preventing complications Ensure that the insertion site is visible at all times This may not be possible with femoral-sited arterial lines Ensure that the flush bag has adequate fluid. Use only 0.9% sodium chloride Ensure that the pressure in the pressure bag is maintained at 300mmHg Do not allow the flush bag to empty Monitor color & temperature of limb distal to arterial line & compare to other limb Never inject anything into an arterial line

44

45 Monitoring is only an adjunct to the careful observation of clinical signs in the critically ill patient.

46 Summary SICK patients are SICK, no matter their location Critical patients need adequate access Arterial Line monitoring is of paramount importance in the critically ill Never let go of the wire Know where you line is Keep it Sterile Manage the PATIENT

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