# Placement of Arterial Femoral (venous) lines



## jross (Jul 23, 2009)

Any one placing radial arterial lines or femoral lines (venous)?  If so what are you using over the wire vs over the needle method, kit or standard IV, how are you securing.

Lastly do you know of any studies performed regarding these procedure being done 
pre-hospital success, infection rates ect….


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## VentMedic (Jul 23, 2009)

Why?

Are you referring to IFT (CCT or Flight) or Specialty transport?

Just in the field as 911 response?

Distance to the nearest facility?

What country or state are you from?

Are you referring to RNs or Paramedics?


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## VentMedic (Jul 23, 2009)

Since the OP did not return with any more information...

This applies to the U.S. and more specially to the areas I am familar with.

Arterial line placement is not part of any Paramedic scope of practice in any state for regular EMS. There have been a few but very few specialty or Flight teams that have sought permission from their state to do that skill for their Paramedics. So yes, it could be part of an expanded scope but to the best of my knowledge, few have included A-line insertion even on CCT or Flight.

If this were to be done in the field by a Paramedic, just like the IV, it would have to be changed once in the hospital. That leaves only one radial artery left to cannulate before looking at the femoral artery.

I also can not see spending much time in the field initiating the line and calibrating the equipment when there are so many other things that need to be done to get the patient to the hospital. I would also not attempt to start an A-line in a moving vehicle in either an ambulance or in a helicopter. Too much damage can be done.

The RNs working with me on the helicopter when I am wearing a Paramedic patch can cannulate the artery if absolutely necessary. However, we may also ask someone at the hospital, especially the RRT, to put in an A-line before or during our arrival. ED physicians may not ahve cannulated an artery since residency. When I am working as an RRT, I can cannulate an artery on IFT, CCT, Specialty and Flight. I can not as a Paramedic. I use whatever device I see appropriate for the age, size and cannulation site requires. We (RRTs, RNs) are trained for different sites with different devices.

The venous femoral line is a central line and although several states do have central lines in their scope of practice, few services will have central line placement in their protocols. The EJ and IO are alternatives and often faster. As well, the field femoral line will have to be replaced with a hospital line that is capable of multiple fluids and for infection control. Of course, they will wait for a stable time for the patient or if at a teaching hospital, one of the residents will establish another line while everyone else is doing other things.

Questions you need to ask:

How many patients do you believe need arterial lines in the field?

Will it make a big difference in your care for prehospital EMS?

How long do you want to stay on scene?

If you are concerned about BP, staying on scene looking for a radial artery to cannulate may not be good use of time for that patient.

Are you going to try both radials and leave the hospital with the opportunity for a radial cannulation?

Do you not have an IO that could work for a line placement if peripheral, including the EJ, is not possible?

Where will you be able to perfect your skills?


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## medic417 (Jul 23, 2009)

I am aware of just a few ground 911 services with them in the protocols.   Most still just get an IO if no IV site found.  So it just does not seem to be a practical item to add.


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## VentMedic (Jul 23, 2009)

medic417 said:


> I am aware of just a few ground 911 services with them in the protocols. Most still just get an IO if no IV site found. So it just does not seem to be a practical item to add.


 
You are referring to the venous femoral line and not the radial A-Line?


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## Flight-LP (Jul 23, 2009)

We still carry femoral kits, but rarely use them due the already mentioned simplicity of the EZ IO. One exception though is if we have to start pressors; we will either put in a fem line or put a RIC into a pre-existing access.

Arterial lines are a different beast. We can and do use them, usually transduced for continuous BP while on the aforementioned pressors or in general for hemodynamic instability. It also allows repeat ABG's on the i-STAT. It is a nice option to have available..............


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## VentMedic (Jul 23, 2009)

Flight-LP said:


> Arterial lines are a different beast. We can and do use them, usually transduced for continuous BP while on the aforementioned pressors or in general for hemodynamic instability. It also allows repeat ABG's on the i-STAT. It is a nice option to have available..............


 
Are you inserting these A-lines at scene on a HEMS call?

Are you suturing them in place?


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## Flight-LP (Jul 23, 2009)

We do not do scene calls, only specialty transport / IFT's. If I have 2.0 or 3.0 silk immediately available, then yes we will suture them. Usually we will steri-strip and then tegaderm the site. Not optimal, I know, but better than nothing..........


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## VentMedic (Jul 24, 2009)

A link you might be interested in is this one from Flight.web.  I believe this was for RNs although Mike is an EMT-P.


http://www.flightweb.com/forums/index.php?showtopic=1952


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## medic3416 (Jul 26, 2009)

jross said:


> [_I]Any one placing radial arterial lines
> 
> Only by accident when you get the dreaded, “o' crap the bag turned into cool-aide”. In which case you remove it and use a good pressure bandage:blush:._


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## daedalus (Jul 26, 2009)

Unheard of in California. However, I see very very little benefit in placing an art line in the field. Transducing pressures should be left to the ICU.


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## VentMedic (Jul 26, 2009)

daedalus said:


> Unheard of in California. However, I see very very little benefit in placing an art line in the field. Transducing pressures should be left to the ICU.


 
I agree about placing an A-line in the field. However, for CCT, Specialty and IFT Flight, they are truly nice to have. This is especially true if they are a ventilatory nightmare and you do have an iSTAT available.

From Flightweb.com I found out the OP is part of an RN/Paramedic flight team although I don't know if he is the RN or the Paramedic.  Even for CA, that would change things if he is the RN as they can do A-lines if I remember correctly.


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## jross (Jul 27, 2009)

*Art Line*

Well just to clear a few things up.....

Yes this would be for a flight program and yes it would be as an RN/EMT-P team. I don't see much of a benefit for an A-line for a scene call but for an inter-facility thats a bit diff. Lets put together a scenario, sick cardiac pt or septic pt on a strong vasoactive medication with very labile BP. Essentially a radial arterial line is a pretty benign procedure (there are many of you doing much more risky things in the field than art lines). Wouldn't an arterial line be beneficial in controlling this situation.

Pls dont critique grammar, didn't really want to waste time with that you get the message.

Joe

And yes same post is on flight web


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## maxwell (Aug 6, 2009)

Art lines in the field?  oh god no.  for what?  art lines are meant for longer term mgmt of hypotension with pressors on board, or if things smell like you may need pressors soon.  If a pulse is sketchy in the field, fill the tank then give your favorite flavor of pressor (depending on why you're giving it).  Central lines in the field?  Old school.  Bad idea back then, still a bad idea today.  I'm sure some of us can be great at it - but - think of the line sepsis and how much it will get misused!  And the pain!  And some idiot, I know, will try to do a subclavian!  and the pt will get a ptx!  Disaster!  If you're pressed for access, use an IO, and give 'em diesel.


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## Akulahawk (Aug 17, 2009)

A-line in the field? Most of the time, I just don't see the need to place one. Perhaps with some VERY remote patient thats VERY unstable and you're going to have a long transport time. I've been part of many transfers where one was in place... but, like those above, it was for patient that needed to have continuous BP monitoring and those patients with the A-line almost always had some vasoactive meds going... and going from one specialty unit to another specialty unit at another facility.


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## medic_texas (Aug 22, 2009)

Placing an art-line in the field (pre-hospital) is too time consuming.  If they need an art-line, they probably need a higher level of care more.  You can't just pop in an art-line and start reading it.  Just the set up alone takes a few minutes, then the actual insertion of the catheter, and finally calibrating and ensuring your transducer is in place.  

But if you do have an art-line, it's awesome to have.  I love art-lines and when you are titrating drips, it's nice to have a real-time BP.

Art-lines have no business on ground ambulances and flight crews should only use them with inter-facility patients.. IMO


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## rescue99 (Aug 22, 2009)

Not even all CCT units don't necessarily have art-line or ICP monitoring capabilities...GRRRR! Pressure bags and in line ventric monitoring might be all that is available. Until and unless the appropriate monitoring capabilities become the standard, placing an art-line should out of the question. Takes a few miutes to place an art-line and a few to set one up anyway.


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## Flight-LP (Aug 22, 2009)

rescue99 said:


> Not even all CCT units don't necessarily have art-line or ICP monitoring capabilities...



Then they are lacking the capabilities that are advertising. If you cannot perform invasive monitoring, then what is the differentiation between them and any other ALS / MICU truck? 

CCT is an ambiguous term. I have seen many places offering "critical care" simply by putting a second paramedic on a unit. I prefer the term specialty transport and for that you need an educated and experienced crew backed by strong medical leadership, sound current medical guidelines, and all necessary equipment to support the care of your specialized transports.


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## rescue99 (Aug 22, 2009)

Flight-LP said:


> Then they are lacking the capabilities that are advertising. If you cannot perform invasive monitoring, then what is the differentiation between them and any other ALS / MICU truck?
> 
> CCT is an ambiguous term. I have seen many places offering "critical care" simply by putting a second paramedic on a unit. I prefer the term specialty transport and for that you need an educated and experienced crew backed by strong medical leadership, sound current medical guidelines, and all necessary equipment to support the care of your specialized transports.



SPELL CHECK PLEASE!!!! Sorry about the ooops!


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## rescue99 (Aug 22, 2009)

Flight-LP said:


> Then they are lacking the capabilities that are advertising. If you cannot perform invasive monitoring, then what is the differentiation between them and any other ALS / MICU truck?
> 
> CCT is an ambiguous term. I have seen many places offering "critical care" simply by putting a second paramedic on a unit. I prefer the term specialty transport and for that you need an educated and experienced crew backed by strong medical leadership, sound current medical guidelines, and all necessary equipment to support the care of your specialized transports.



Wasn't an arguement Flight...just making a statment based on observations is all.


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## Flight-LP (Aug 22, 2009)

rescue99 said:


> Wasn't an arguement Flight...just making a statment based on observations is all.



never assumed you were.......


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