14 gauge needle (Harpoon)

[mycrofft]

Go to the science...what are the chances of a given gauge not working for

...a given job?
Teeny caliber equals haemolysis and slow infusion.
Huge caliber equals higher chance of either you or the next person blowing a recipient vein.
Huge calibers for cutdowns and used as trochars for decompression?
If nothing else, big cylinderical sharps are the best for extracting foreign objects, don't flex, sharp blades and the sharpest tips.

 

[downunderwunda]

A nurse gave me :censored::censored::censored::censored: for suggesting a 14 gauge in the AC for a shocky patient. She believed if you could get a 20 gauge, that would do. She also told me that she hated the fact that medics were starting 14’s on patients because they do so much damage to the vein.

Bottom line is you need to get that BP up ASAP. The bigger the needle, the faster the fluid goes in.

What gauge do you guys use for shocky patients???

This is the mentality that gets pre hospital practitioners a bad name. I have worked alongside doctors in a Major Multi System Trauma who refuse to use anything bigger than an 18, or maybe a 16g.

For my own benefit I asked why & was told the flow rates & rate of infusion between a 14g & an 18G will not make any real difference to the patient.

Yes the shocked patient needs fluids & fluids fast, however, let me ask you, if the patient is as bad as you are making out, wouldnt they be close to irrevesable shock. If this is the case, why did you let them get that bad. Conversley if that is how they were when you found them, give yourself a reality check & remember some patients die. Regardless of what gauge cannula you use.

Personally i have had an argument with a colleague over 14g cannula's & he was free to admint the 14g is more a 'Cause I can' option that needed by the patient option.

Be safe

 

[piranah]

since ive been in the er the biggest ive seen used is a 16g for a massive burn pt... i use 18s/20s...

 

[reaper]

Trauma bilat 18's, maybe a 16 at the most. My usual IV in a medical pt is a 20, that is all most need.

We do carry 14's, but I refuse to use them.

I crushed a firemedics ego a few weeks ago. Picked up an elderly NH pt that fire had FR to. This guy was so proud of his IV, till I pulled him outside and rips his arse. He had put a 16 in the back of the hand, on a 84 yo F who was mildly dehydrated. He could not understand why I was so pissed off!!

 

[41 Duck]

I found that when I did my hospital clinicals - even in the ER - 20s and 22s were the norm. The nurses hardly ever stuck 18s in anyone, even those needing fluids.

During my ED clinicals, I saw an 18 used twice. In real life, however, 18 seems to be the norm--at least in my area.

I know it's likely to open the proverbial worm can, but I wonder if prehospital usage of the 20 gauge would increase if they carried a different color code. That they're pink shouldn't make a difference... but I believe it does.


Later!

--Coop

 

[reaper]

No it has to do with bad instructors pushing the "biggest you can get" BS in schools!

 

[Bosco578]

A line is a line. What do you need it for? Fluid? Med route?. I have started various sizes. 22-14g. Typically 18-20g. Trauma usually gets 18-16g. I have started my share of 14's. However, 18's are pretty common and 20's more so. It all depends on your needs. Does a 14 hurt more than a 20? When the line is patent does it really feel better or worse than 14 or 20?

Different sytems, different protocols.:deadhorse:

 

[Scott33]

Trauma bilat 18's, maybe a 16 at the most. My usual IV in a medical pt is a 20, that is all most need.

We do carry 14's, but I refuse to use them.

I crushed a firemedics ego a few weeks ago. Picked up an elderly NH pt that fire had FR to. This guy was so proud of his IV, till I pulled him outside and rips his arse. He had put a 16 in the back of the hand, on a 84 yo F who was mildly dehydrated. He could not understand why I was so pissed off!!

...and what are the chances that he had microdrip tubing attached to the catheter?

The fact that he wanted to put something so large (presumable to infuse large volumes of fluid) into such an elderly patient, shows his lack of understanding in A & P. The go large or go home mentality is precisely the reason many agencies now are advocating the use of saline locks, over KVO drips. To many instances of fluid overload in patients with CHF / ARF / CRF / ESRD

But as already mentioned, if the patient in the original post was that hemodynamically embarrassed, there are more options available.

Bilateral 18s would do more than a single 14g, and failing that, there is always dopamine. IOs are also quick, easy, and paragod-proof.

 

[flhtci01]

During my ED clinicals, I saw an 18 used twice. In real life, however, 18 seems to be the norm--at least in my area.

I know it's likely to open the proverbial worm can, but I wonder if prehospital usage of the 20 gauge would increase if they carried a different color code. That they're pink shouldn't make a difference... but I believe it does.
--Coop

During my ER clinicals, 18 was the norm. I was even told once to start a larger one on a non-trauma pt.

This was at a large teaching hospital. The nurses motto was "Go high, go large or go home."

Not saying it was right, just the way it was.

 

[PapaBear434]

Nurses also have to start another IV even with a field stick...especially if it is a 14g needle which can create problems AND especially in the AC. Unfortunately they may not have much to work with after multiple sticks with a 14g in the ACs. If you want an IV to last at least for 48 hours, be thankful the nurses do have a controlled environment. It is not about the ego of who can do what where but what is best and safest for the patient. Nurses are always thinking about the long haul as well as the emergent situation. That makes for a slightly different focus than EMS providers.

Patients sick enough to get a 14g will probably have a lengthy hospital stay. Hopefully the veins will last long enough to get a central lline established. A blown vein with a 14g running fluids is not a pretty sight and can lead to some nasty complications if not caught immediately.

Not disagreeing. It's rare we ever put in anything larger than a 20. Trauma usually only gets an 18, and I've only ever seen a 16 dropped in the field twice.

 

[Veneficus]

Weighing in.

I have admittedly used more than my fair share of 14 gauge needles. (I have spent a few years working in an "ivory tower" of trauma) Let us not forget, that not too long ago we thought that as much fluid as fast as possible was the best treatment. 14 gauges connected to rapid infusers, pressure bags, etc were the gold standard. I have seen people bleed cool-aid a few times. Now we know better. But like with all EMS practices it seems, old habits die hard.

As for my thoughts. Most people do not require a 14g. But it is a good temporary substitute for a central line. I have even seen on numerous occasions surgeons decide on not putting in a central line because there was a 14g in. The 2 inch catheters are less likely to come out than the shorter ones from inadvertent pulling or inadequate taping. I would agree you might be destroying a few more capillary beds and some connective tissue, but I doubt it causes any more significant harm than any other needle. When you pull a large bore catheter probably a good idea to put some significant pressure on it at first. I have never seen a properly placed 14g blow. If you just get the tip in and try to run it wide, that is your error, not equipment failure. As a bonus, you can reach deeper veins with the longer catheter, unless you are really lucky and carry those 3” long 18 and 20s used for ultrasound insertions. Not too mention bigger is better when decompressing a chest.

I would hope when I am in the hospital (ie: sick by my standards) that people will use at least an 18g on me. If I don’t need rapid volume, I probably don’t need a hospital. I have let people put 14s in me to practice. If you find me on the side of the road bleeding, I will not be upset if you stick me with a pair of 14s. I would be upset if you put a 24 in my hand because “you can run blood through it.” You can drain a toilet with a straw too, doesn’t mean it is a good idea. In fact don’t mess with my hand at all, too much there that can go wrong.

A 14g is a tool, like every other tool, it has a place and a time. But here’s a rub. If you don’t tube very often, you are not good at it. If you do not use large needles very often, you will not be good at it. So don’t go around putting them in the hands of 80 year old ladies but from time to time it may help if you practice doing one or two.

From my experience, anyone who thinks you don’t get more volume out of a 14 than an 18 might want to revisit their biophysics notes as well as do some simple experiments. Those catheters move fluid, especially autotransfused blood.

 

[remote_medic]

Running blood through a 24g IV works just fine. The issue is when you try to run it under PRESSURE either by way of an IV pump or pressure bag that you cause hemolysis. Under a gravity drip situation blood will not be dammaged via a 24, and it will take about 3 hours to run in a unit (which is plenty fast in a large portion of the population)

I'm following this discussion with a lot of interest. It is interesting to see the view points between providers who also work in a hospital environment vs a strickly out of hospital environment. I work both (as do many here) so I can see both points of view (long term vs short term).

Here is another thought...yes we all agree that there is the rare patient that needs 14 or 16 gauge IV, do you want the paramedic who is putting it in with little to no experience inserting an IV of this size? It is a slightly different technique, requires a bit more force to thread, etc. I've had some paramedic partners say they choose to put in a 16g in patients that are "borderline" sick because they want the practice with larger IV's. Just some food for thought

 

[boingo]

In hypotensive trauma patients 14g is our standard catheter, assuming they have the vasculature to accomodate it, 2 is even better. We may not be running fluids wide open, however when we skip the ED and go straight to the OR with a patient that is atensive with a stab wound to the liver, the surgeons really appreciate it. I'm not suggesting every pt with MOI needs a 14g, I have used plenty of 18's and 16's instead, but for those patients who are going to need a lot of blood quick, you can't go wrong with a 14g IMHO. As for decompression, 3" 10g is the catheter of choice.

 

[BossyCow]

Cruel and unusual punishment???? Myself and one other student let people start 16 and 14 ga. IVs on us in class. Yeah they left a bigger mark afterwards but painful???? Not really!

 

[lightsandsirens5]

I used a 14 in my dairy cow. Does that count?
Of course I did swich to a 10 gauge later to get fluid in faster.

 

[BossyCow]

I used a 14 in my dairy cow.

I certainly hope that's not a cow joke!!!!

 

[Veneficus]

Running blood through a 24g IV works just fine. The issue is when you try to run it under PRESSURE either by way of an IV pump or pressure bag that you cause hemolysis. Under a gravity drip situation blood will not be dammaged via a 24, and it will take about 3 hours to run in a unit (which is plenty fast in a large portion of the population)

I'm following this discussion with a lot of interest. It is interesting to see the view points between providers who also work in a hospital environment vs a strickly out of hospital environment. I work both (as do many here) so I can see both points of view (long term vs short term).

Here is another thought...yes we all agree that there is the rare patient that needs 14 or 16 gauge IV, do you want the paramedic who is putting it in with little to no experience inserting an IV of this size? It is a slightly different technique, requires a bit more force to thread, etc. I've had some paramedic partners say they choose to put in a 16g in patients that are "borderline" sick because they want the practice with larger IV's. Just some food for thought

The occasional practice I think is good. As you said, it is a different animal.

My hospital experience is high volume, high acuity trauma and burn, from that perspective 3 hours for a unit of blood in many of our patients simply would not do until after surgery. Those really sick patients are not a question of if, but how many on a given day.

 

[remote_medic]

The occasional practice I think is good. As you said, it is a different animal.

My hospital experience is high volume, high acuity trauma and burn, from that perspective 3 hours for a unit of blood in many of our patients simply would not do until after surgery. Those really sick patients are not a question of if, but how many on a given day.

I agree 3 hours for a unit of blood is a long time for some patients. I too work in a high volume trauma ICU (very few burns thankfully) I'm not saying a 24g IV is ideal, but can work for some patients.

 

[lightsandsirens5]

I certainly hope that's not a cow joke!!!!

'course not bossycow! btw, How did you pick that name?? Do you have a cow?

Mine is a Jersy, she is pretty bossy!!

 

[MSDeltaFlt]

The phrase "good enough" is not good enough when you're talking about pt advocacy. You don't look at the gauge size. You don't look at the color when determining what gauge to use. You look at your pt's status and the size and quality of the vein.

Look at your pt. Assess your pt. Ask yourself these questions.

1. Is my pt sick? If yes, assess for need for IV.

2. Does my pt need an IV? If yes, assess if stable and needing IV or unstable and needing IV.

3. Is my pt stable and needing IV? If yes, just get IV large enough to maintain flow and give meds as needed.

4. Is my pt unstable and needing IV? If yes, then assess vein. Get the largest catheter that the vein can hold without blowing and that you can access with as few attempts as possible.