Central Lines

NomadicMedic

NomadicMedic

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I'm curious who is still placing Subclavian central lines in the field. Obviously, HEMS is excluded from this...

I just learned that our MPD would like us to place them in major trauma patients and codes. :unsure:

I thought they fell out of favor due to high infection rate and complications... plus, my EZ-IO is so much quicker.
 
A subclavian? I've seen one or two done, but... not in the field. Is your doc wanting your people to use blood tubing with that setup too? Single Lumen or some kind of multiple lumen catheter? I'd be concerned about infection, possible air embolism, but my biggest worry? Time. How long does it take to place a SC line (single lumen) vs an EJ?

I'm actually wanting to know this stuff... It's not in our scope down here.
 
I've seen it attempted in the field once without success.
 
I am aware of a few in Texas that do it. If they resort to doing it though infection is the least of that patients worries.
 
Just a single lumen cath, and standard tubing. It seems like a huge liability in terms of contamination and infection.

And yeah, I haven't done one on a living (or dead) person. Just a bunch of practice on the manikin. I think I'm still gonna look at an EJ or IO before I start digging around for a subclavian.
 
Not sure that trying to do central lines in the field will help your scene times. Nor if most medics get enough experience to be good at central lines. Thirdly you can give more fluid through a short large gage IV than a central line.
 
I don't see it as necessarily "too dangerous". My biggest concern is the time it would take to start the line. Flow rates, infection, and so on are all things that can be dealt with... but you can't get the time you used up to put the cath in. For those of us that don't have the ability to do IO's in adults, I think it would be a nice thing to be able to place IF nothing else can. For field work, I'd much rather do an IO instead...
 
I'll have another conversation the Doc and find out the reasoning behind this new love of central lines.

As an aside, I was told this morning that the EMS Chiefs and the doc decided that our department will continue to place IOs and that we will NOT to place subclavians, unless it's a "last resort".
 
n7lxi said:
I'll have another conversation the Doc and find out the reasoning behind this new love of central lines.

As an aside, I was told this morning that the EMS Chiefs and the doc decided that our department will continue to place IOs and that we will NOT to place subclavians, unless it's a "last resort".
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Washington state has the most advanced EMS in King One. I hear they can do a lot but that the program last twice as long as most in the nation.
 
The King County Medic One education program at Harborview certainly intense. Dr. Copass and the gang make sure they keep the pressure on. However, the didactic portion is the pretty much the same at every program. Where they excel is the sheer number of patients the medic students see. At Harborview, it's not uncommon for medic students to leave with 40+ tubes and over 250 IV starts.

But, as for the protocols, you'll find most in western Washington are similar, with many of the rural counties even more progressive than KCM1. For example, KCM1 doesn't carry CPAP or start IO lines.

As a point if interest, the Seattle medics still operate on a "mother may I?" system, calling to confer with a doc for even the most routine cases, i.e.: Known diabetic, found semi conscious, diaphoretic and a blood sugar of 40. They STILL must to call and ask to check a BGL and ask for permission to administer D50.
 
Thought Copass retired? Also be interesting to see if the medic students are still getting those kinds of tubes once Seattle gets their emergency medicine residency back.
 
I've seen 2 done...in the field. We generally do the Sternal IO in bad situations, when we can't get a line established anywhere else.
 
zmedic said:
Thought Copass retired? Also be interesting to see if the medic students are still getting those kinds of tubes once Seattle gets their emergency medicine residency back.
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Copass will be involved in medic one until the day he dies. And Seattle medics get a lot of tubes. The students ride on medic 1 and medic 10, so there are plenty of "out of hospital" tubes to be had.
 
Simply not practical to do in the field. If someone needs a central line that badly, we resort to IO
 
n7lxi said:
But, as for the protocols, you'll find most in western Washington are similar, with many of the rural counties even more progressive than KCM1. For example, KCM1 doesn't carry CPAP or start IO lines.
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I've seen SFD medics start an IO line on one patient in a memorable occasion involving a good 30-40 minutes of failed IV, EJ and central line attempts beforehand. While about a 2 minute drive from 3 different hospitals. Not quite what I would have done in their place, but I'm just an EMT. What do I know? :P
 
That's interesting. I know that they don't carry an IO kit like FAST, BIG or EZIO. They must have used a Jamshidi that was for pedi cases.

A KCMO medic smugly said to me, "We don't EVER do IOs. We were trained to do central lines."
 
n7lxi said:
That's interesting. I know that they don't carry an IO kit like FAST, BIG or EZIO. They must have used a Jamshidi that was for pedi cases.

A KCMO medic smugly said to me, "We don't EVER do IOs. We were trained to do central lines."
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Yeah, I'm gonna have to differ with ya, I was there working with Tri-med, E18/19, M4 on a MVA when a line was put subclavian on a patient in the vehicle while the vehicle was being cut away around us. But it's not every day that someone tacos their cadillac around a telephone pole... And while I'm not sure about Seattle FD, since I don't work in the city, but Glucometry is a BLS skill without online medical control, so I'm a little confused as to why ALS would need to ask med control... And about IOs they're good for 24hrs, I'm not sure with a 5min +/- transport time, that there is a justifiable reason, especially if they can get a central line.
 
Luno said:
Yeah, I'm gonna have to differ with ya, I was there working with Tri-med, E18/19, M4 on a MVA when a line was put subclavian on a patient in the vehicle while the vehicle was being cut away around us. But it's not every day that someone tacos their cadillac around a telephone pole... And while I'm not sure about Seattle FD, since I don't work in the city, but Glucometry is a BLS skill without online medical control, so I'm a little confused as to why ALS would need to ask med control... And about IOs they're good for 24hrs, I'm not sure with a 5min +/- transport time, that there is a justifiable reason, especially if they can get a central line.
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I would be very, very supprised if field placed central lines were left in for more than a few hours at most. Line sepsis is not a good thing.

The nice thing about EZIO is realisticly I can place one faster than an IV, much less setting up for a subclavian.
 
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Luno said:
Yeah, I'm gonna have to differ with ya, I was there working with Tri-med, E18/19, M4 on a MVA when a line was put subclavian on a patient in the vehicle while the vehicle was being cut away around us. But it's not every day that someone tacos their cadillac around a telephone pole... And while I'm not sure about Seattle FD, since I don't work in the city, but Glucometry is a BLS skill without online medical control, so I'm a little confused as to why ALS would need to ask med control... And about IOs they're good for 24hrs, I'm not sure with a 5min +/- transport time, that there is a justifiable reason, especially if they can get a central line.
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Yeah, agreed. They put in subclavian central lines as a matter of routine, NOT IOs. The King County medics don't carry a commercial IO device.

And yes, the Seattle firemedics call for EVERYTHING. Listen to the "Medic One Doc" or "Trauma Doc" talkgroup on the Seattle Radio System sometime. You'll hear stuff like this all day long: "Hi doc, It's Medic 10, I am seeing a 50 year old male with 10/10 substernal chest pain, diaphoretic, short of breath. I'd like permission for an IV, 234 of ASA, 0.4mg on Nitro times 3 and 2 plus 2 of Morphine, up to 10..."

While they almost always get the orders, they DO have to ask permission for EVERYTHING. Including BGL and D50.
 
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