Cut to the case!
Emergency doctors discuss cases and how to manage tricky situations in the Emergency Department.
Cut to the case!
Vascular access in Shock Trauma
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It’s all about access! Hot on the heels of our vascular access workshop, Jonathan and Emma are joined by Jess Thomas to discuss strategies for vascular access in a shock trauma case who has none.
The focus is and the first question I ask paramedics as they're coming down the corridor is what's your vascular access? It's all about vascular access because every intervention requires vascular access. Hi, it's Jonathan.
SPEAKER_00So Emma, how's it doing?
SPEAKER_02Great. How about you doing?
SPEAKER_00I'm good, but I'm what have you got me here for? I've got a case. I have got an interesting trauma situation that happened the other day. It's a uh so get this right. So we've got a 45-year-old male, he's coming via helicopter, he's been in a uh car accident, his ute has been crushed, uh, and we hear that he's shocked, he's got head injuries, chest injuries. He's been he's had he's been in difficult intubation, so he's got a um an I gel laryngel mask in here, he doesn't have an endotrecheal tube in. Um he's had both sides of his chest decompressed because he's got chest injuries. Um his blood pressure is 70 on 40, heart rate 135. He's had some blood in the helicopter and he's coming. Okay, so that's the situation. We're worried about pelvis as well. Okay, we're worried about the whole gamut, he's got a binder on too. Okay. Okay, so we're ready, we do all the normal stuff. Comes down the hallway, and the ambulance, the first thing that you know, I say to them, Do you eat do you need anything right now? And they say, Yeah, we've lost access. We've got no access. Yeah, okay. What do you do?
SPEAKER_02Well, um, for a shock trauma patient which he's he's that person that has that critically low blood pressure below 90 and high risk, you know, their face is mashed, their chest is mashed, their pelvis is mashed. So immediately it's all about vascular access because every intervention requires vascular access. So even before you told me about the uh tissue, you know, the focus is, and the first question I ask paramedics as they're coming down the corridor is what's your vascular access? So, how fortunate we are to have uh Jess Thomas here. Hi Jess, how are you? Welcome, Jess. How are you? Uh Jess is one of our emergency physicians at Rome Melbourne Hospital. She's also um uh heavily involved in our trauma care and does our trauma audit, and today she's running our vascular access course. So thanks Jess, you're here as the expert relating to vascular access. Do you mind if we quiz you? Not at all.
SPEAKER_00What are you thinking about with this? So we thought that's it. We thought we'd get our expert in to adjudicate because we might have different ideas about what to do next. What do you reckon? What do you reckon, Jess?
SPEAKER_01So I think uh the important part of this, as far as I would think, would be making sure you've got lots of plans. So you know, this is not a patient where you've got one size fits all and you're gonna be able to get an immediate line in and fix your problem. So it's gonna be a difficult patient, and so you really need a plan A, B, and C in this scenario.
SPEAKER_00Um, I think it uh it that requires lots of team members and uh we've got plenty of people there, we've got actually got plenty of skilled people there keen to do stuff, but I guess my my my thinking is what's my first step? What sort of line do I need? Um I can tell you what happened, a big one. Yeah, yeah. Yeah, yeah.
SPEAKER_02So you've got lots of options, haven't you? You've got peripheral access, you've got peripheral access plus, so meaning either Rick Line ultrasound, you've got IO, and you've got a MAC sheath or a subclavian access or other femoral access. Yeah, yeah. Um what what would you tell your team as this patient's coming down the hall, the blood's hanging? Sorry, we've just lost our only access. What do you think you'd do?
SPEAKER_01So I think uh uh particularly as the team leader, the most important thing here is to identify that that is the main issue. So you need to speak that to the room that the priority is vascular access and uh resuscitation, because I think that then tra uh shifts the entire focus of the team from all the other injuries to actually this is now lines, this is the priority.
SPEAKER_00You're right, because this this looks like you know a traumatic arrest about to unfold, but actually, like with the difficult intubation, when you say this is a difficult intubation, everyone kind of locks on and goes difficult intubation. Yeah, you can say this is a vascular access emergency, this is a difficult vascular access situation, and maybe people will reset the priorities.
SPEAKER_01Exactly. Um, and that sort of uh includes re-prioritizing staff like your aneneathetist who might be able to help with vascular access rather than being at the head end of the bed. Yeah. And I think um the important thing here is yeah, having your plan and redeploying staff where you need them to start with peripheral lines but with a very quick, rapid escalation process.
SPEAKER_02So just for a second, this is my turn to talk. And I agree with you, you can't have one plan because all one leader. You might or one speaker, that's it. Imagine if we were both having this. You might find unanticipated injuries, and the unanticipated injuries that really make vascular access very difficult are apple infractures. Yes. So, you know, you've got this patient coming in, you're like, we're gonna start with peripheral vascular access, let's get two tourniques ready, we're gonna go for a minimum of 18, 16, we'll convert one to a RIC. And then as they're coming in, you see that arm smash, that arm smashed, then that plan goes out the window. So you need to be ready to give it back to your children.
SPEAKER_00So in in that situation, I would say, well, this is definitely a difficult IV access scenario if you've only got one arm, so you're already in that category. Yeah, um, I tell you what, I like your idea, Emma. I don't like your idea of talking over there. I like your idea about getting the the two people working on the arms at the same time, upgrading it to a RIC. But in this case, I reckon I put an IO in, and that's what we actually did because I'm worried about the no airway thing. He's got an eye gel in, he doesn't have a protected airway. He might wake up, something might happen. I want an emergency line. So, what do you think, Jess, about putting an I/O in straight up?
SPEAKER_01I think there are definitely some benefits to the I.O. it uh particularly for sedation drugs and for ongoing resuscitation. Um, there is the consideration though that it isn't uh it isn't a large bore line, and so I think it's a interim measure. Interim measure.
SPEAKER_02Yeah, okay, yeah, and then the tricky part is also that this patient's got the other a couple of other issues pending. So there, you know, is that I gel enough, um, but also the bilateral chest decompression, they probably really need to go to be interrogated again, make sure that they're patent. Now that's gonna require some movement, so the patient's gonna have their arms out. Guess what?
SPEAKER_00The minute you put the and remember the IO, arms like that, drill like that, you can't put the chest tube in. Yeah, so that's not gonna work. So actually, that's gonna fall out. Okay, um, yeah, the arms are gonna go up that way to get the chest tube in. So maybe not a good idea.
SPEAKER_02But let me tell you what I would do. Uh, I would have you're on the right, you're on the left, two tourniquets on, let's um try for some peripheral access. And then after that, what I'm really wanting is clear communication from those people who've been uh tasked. I want to know can you get it in? Are you reaching for ultrasound? Which means to me that it's gonna be very difficult, and I immediately need to enact my secondary plan, which for me will be a um right subclavian line.
SPEAKER_00How just on that, how long do you give them? I mean, you know, they're they're they're doing the procedure. How long do you give someone? Yeah, how much time do you give them before you say, hey, how's it going, or oh, it's not working, or how many goes? Do you have a rule?
SPEAKER_02Yeah, well what I do is I sort of uh say it out front. So I'll say, you know, vascular access is you know our critical intervention. Really, we need to try and establish it within 90 seconds. Can you let me know how you're going because then I can bring in the next plan? 90 seconds. Yeah, but it's 90 seconds with why. So it's 90 seconds because then I can bring up my next plan. So then they don't feel like failures because it's hard. And you know, you fail plenty of peripheral lines. But if they know why it is that I want the next step, then that's important. Because it could take a white thing.
SPEAKER_00So what do you reckon? How long would you give them? And do you agree the why?
SPEAKER_01I I'd agree, I think sort of 60 to 90 seconds is a is a good checkpoint. I don't think that says that they have to stop at that point, but I think that's when you start initiating plan B if we're struggling.
SPEAKER_04Yeah.
SPEAKER_01Um, in this scenario though, I would honestly ask someone to be scrubbing for the subclavian from the start because of the time taken to set up.
SPEAKER_00We were lucky in this case because we we knew that he had the chest injury. So we actually had two people scrub. We had an emergency person on one side, surgical person on the other side, emergency person on the right. So the emergency person was on the patient's left. Okay. Yeah, yeah, and the surgical person was on the patient's right. Why do you say that?
SPEAKER_02Well, it just makes sense to me to have the emergency person on the right because they can do both the chest and the right subclavian. And not to say that the surgical peop person can't, it's just that more often that skill set lies with ED people. So I would preferentially have that. Should the patient then need a theracotomy, you've got the surgical person on the left. Yeah. Yeah. You know that.
SPEAKER_00No, it's yeah, it's it's it's it's it's a tricky thing, but are you yeah, yeah. So so we had them pre-scrubbed, so we were able to go, okay, you've had an I go two goes two minutes, either side, IV line. You know, two and two, just easy to remember. Yeah, but I I take your point. So the question is, why is it difficult? And and I like it. If you're reaching for the ultrasound, it means you're in trouble. Like if you're got one arm missing, you're gonna be in trouble. So it's basic stuff. Placement of the ultrasound though, where do you put it?
SPEAKER_02Like you mean because there's um difficulty getting to the patient? Yeah, yeah.
SPEAKER_00Like because the ultrasound is usually on the patient's right hand side. Yeah. Yeah, okay, because we're doing the fast on that side. So that means the person standing on the patient's left hand side is probably in the best put place because you want to reach across, don't you? Yeah. And you put a line in. Yeah, what do you do, Jess? What what do you recommend if you're going to use an ultrasound?
SPEAKER_01So um my practice is also always, if I think we're gonna have trouble with vascular access, is to have a second ultrasound on top of it.
SPEAKER_00Two ultrasounds. I like it.
SPEAKER_01Um, and it's just sitting outside of the room. So it's outside of the space, so if you don't need it, it's not cluttering next to the patient. But it also means that you're sort of only a couple of steps away from grabbing another one because uh I don't want to be taking that ultrasound from the person doing the E fast because what they find might change our trajectory as well. Yeah, yeah.
SPEAKER_00Great. I like it. Get the two ultrasounds. Yeah, good.
SPEAKER_02And I guess just to unpack the reason that you might have peripheral difficulty is because they're shocked and everything's you know shut down and the uh subclavian vessel is held open by adventitia. So that's why that's what they say, right? That's why that's why we're going to do that.
SPEAKER_00That's what they say, held open by adventitia. Yeah. What happens if there's a pneumothorax? Is it still held open? Oh yeah, just I don't know. Okay anyone out there, please tell me the answer because I was thinking about this last night, right? Because yeah, it's held open, right? It sucks open if you've got a pneumothorax, is it?
SPEAKER_02Well, no, if it's under tension, presumably there is no pressure. I don't know.
SPEAKER_00I don't know. Uh there's a question for you at home. Um, but uh so subclavian, good idea.
SPEAKER_01RIC line. Uh RIC line?
SPEAKER_00Yeah.
SPEAKER_01I think under uh Rick lines are a very underrated lack.
SPEAKER_00Actually, actually, not everyone knows what a Rick line is. It's uh like not everyone knows. What's a Rick line?
SPEAKER_01So it's a rapid infuser catheter. So they're a larger bore, shorter line designed for rapidly infusing large volumes of fluid.
SPEAKER_00So it's short and fat, it's like eight french or something.
SPEAKER_01Yeah, so seven, seven to eight and a half, depending on the patch.
SPEAKER_00So we can squirt stuff in really quickly. Yes. And the advantage is you can stick it in a vein that's already there, like a cannula, you can dilate it up, stick it in and run it. So, yes, the seldinger technique. Yeah, sort of. Any, yeah, exactly, seldom technique. Thanks for correcting me. Uh any problems with RIC lines in your experience, Ted?
SPEAKER_01So the downside of them is the vessel's got to be big enough to hold the Rick line. And uh the other consideration is because you're putting such a big line in a vessel, sometimes they don't draw back. So people get into trouble trying to take bloods and things off them. Yeah, it doesn't draw back. Um and then sort of freak out and think that the line isn't in because it's not drawing back when actually it's designed just to be used for infusion and giving. Yeah.
SPEAKER_00Yep. Do you um if you just had one access, would you put a ricked line in? Only one cannula, yeah. Or would you always want two? Some people say they'd like to have two accesses and rick one. Are you comfortable with just doing one?
SPEAKER_01I think it depends on how good the line you're using is. Like if you've got a good 18 gauge that's running well, I wouldn't, I'd I'd look for a second line and I would rick the second line.
SPEAKER_02Yep, equally if it's a dodgy line, you're probably not gonna brick it out of that because it's probably not gonna work. No, no, no.
SPEAKER_01It's that in-between cohort where you've got that 20 gauge that's running well enough, but it's not running fast, yeah, um, and you're in trouble, and you know, you can have a quick look and it looks like that vein's gonna be easy and straight, then you want to straight vein to take the risk.
SPEAKER_00You want a cube fossa vein, straight vein. You want to make sure it's a good vein, not a dodgy vein, because the rig's just gonna wreck it and you're gonna lose it. So that's a problem with the rights.
SPEAKER_0260 seconds, because I do like wrapping you up, Jonathan. Uh what about the what about you know, sort of pelvis, uh sorry, um femoral access in this particular case where you're head injury, chest injury, and pelvis injury.
SPEAKER_01I think there is a role still for femoral access in some patients, probably not this patient, until we at least have a pelvic x-ray as to looking at how bad those pelvic injuries are. But I think again, it's an underutilised access point for patients that don't have pelvic injuries, um, especially because it's an area of the patient that often there's not a lot of people, so it's an easy spot to get to.
SPEAKER_00Yeah, we were talking about you know arm space and getting in and doing things, yeah. But what's the problem with uh a femoral line in someone with a pelvic fracture? What's the issue?
SPEAKER_01So the issue is that the vessels sort of proximal to where you've put that line in may be damaged, and so whatever you're giving through that line might not actually be getting into the central circulation. Yeah, yeah, um, but the upside of it is is it is also a very good place for putting double puncture lines in, so you can put a femoral arterial and uh mac sheath in at the same time.
SPEAKER_00Especially if you miss. So it's big on it for the right. So wrapping it up. So and and look, you know, in this case, things went well. We actually got a subclavian in, resuscitated, chest tubes went in, all good. Um so that was our definitive access. But but in summary, so uh have a think about difficult vascular access as a situation, you know, declare it, as you said, you know, just declare it. This is a difficult vascular access situation, especially if they've only got one arm or there's a yeah a limb fracture.
SPEAKER_02And then have a plan for lots of different um approaches because it you know does the branches off. Yeah, do you do uh peripheral plus or minus ultrasound, plus or minus RIC? Do you need to prioritize central that have got no pelvis injury? Do you go femoral because there's real estate there? So lots of different plans. Oh and your IO.
SPEAKER_00And and IO is a safety line. And finally, the you know, the the subclavian line, um, it's a great line, but you need to practice it. You need to people get a bit worried about it, they haven't had a lot of experience with it. Yeah, but practice it, do a workshop, go to our workshop because once you've mastered that, it's great. Yeah, yeah.
SPEAKER_02You really need to get comfortable with doing it and you need to be trained by someone who knows how to do it. The tricks and then you can run through the steps multiple times and then you know be familiar with the equipment.
SPEAKER_00And then just give it a go next time we put a central line in, do a subclavian, keep the practice up. All right, well, thanks Jess for coming. Thanks, Emma. Thank you. That was great. We'll see you all next time. Bye.