Is Venous Cutdown in the Paramedic Scope of Practice

Justjewit

Justjewit

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I am a Vet Tech and we get to do that but now that I am about to get my A and then go to paramedic school I was wondering if that was in their scope as well.
 
I know there is one area in New Mexico I believe that has it in their protocols.
 
I've only heard or read about it being done prehospitally by medics in Washington/Texas/Oklahoma.
 
Very few areas have this in the paramedic scope of practice. I don't know why anyone would want it either. Even in-hospital, it's very much fallen out of favor. I think most clinicians would be apt to use more modern techniques to place a central line. Pre-hospitally, I'd much rather just place an IO. The back of an ambulance is not the place to be excising large amounts of tissue to access central circulation.
 
Seattle/King never did venous cutdowns. They did (and maybe still do) place central lines. A pretty messy, infection prone practice.
 
DesertMedic66 said:
I know there is one area in New Mexico I believe that has it in their protocols.
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Texas, but you are close [emoji14] My old service in west Texas had it in our protocol, but with the advent of EZ-IO and the ability to place femoral central lines, it never got used
NM has a state scope of practice and cut downs are not in it. I suppose that a service could apply for a special skills permit, but they'd have to show a need for it... and there just isnt a need.
 
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The widespread adoption of IO prehospitally and US in the hospital has pretty much nailed the coffin shut on cutdowns.
 
Obviously, venous cutdown is a very specialized skill best left to specialized providers with a demonstrable need. One use I could see is transfusing blood products. Most EMS services don't carry blood products, so this would only be relevant to those that do (rural/frontier, HEMS). I was reading that IO is not the best option in terms of flow rates for blood products in an otherwise healthy, non-osteoporotic patient and that the manufacturers have actually not made any official recommendations in terms of administration of blood products through their devices.
 
I sense that infusing blood through an IO needle is considerably safer and less complex than doing the same through an IV catheter shoved into an exposed vein.
 
I'd think that hemolysis would be of concern when pressure infusing blood products through an IO.
 
I was doing some cursory reading on the IO devices and I couldn't find anything definitive on any adverse effects either way. However, the BIG website did site a study stating that blood products were administered over 2000 test in the sample size and reported a small adverse effect category, although that group did not include slow flow rates (only failure to infuse) nor did it break down rates of complication/failure to drugs vs fluids vs blood products.
 
Venous cutdowns? I learned about those once. With central lines, IO and US guided lines, no one is even taught to do them anymore.
 
DEmedic said:
I'd think that hemolysis would be of concern when pressure infusing blood products through an IO.
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There was a study out about this and it was found to have no adverse effects and actually improved hemodynamics in pig models quickly due to the same bioavailability as a venous route, although I am too lazy to look it up this morning. We carry 2 units PRBCs at work and while IO isn't my preferred route if we have options it will run without issues. We use the humeral site as first access area, and lately I have had them flow as well as a venous line without the need for a pressure bag. I have been pretty impressed with them.
 
ERDoc said:
Venous cutdowns? I learned about those once. With central lines, IO and US guided lines, no one is even taught to do them anymore.
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I've done them in Afghanistan where IO access is contraindicated and the pressure was so crappy that I couldn't get an EJ. I did put a femoral line in once in lieu of a cutdown, but since I'm not the best with a bedside US, cutdown seemed safer
 
Doczilla said:
I've done them in Afghanistan where IO access is contraindicated and the pressure was so crappy that I couldn't get an EJ. I did put a femoral line in once in lieu of a cutdown, but since I'm not the best with a bedside US, cutdown seemed safer
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This brings up a good question.

For those starting central lines in the field, are you taught landmark techniques or are you required to use ultrasound guidance?

None of our residents are taught landmark techniques in my center. And it worries me that we have become so reliant on ultrasound. I'm not even allowed by hospital policy to teach them landmark techniques (subclavians excepted) on live patients, though they are expected to know it for written boards.
 
Nova1300 said:
I'm not even allowed by hospital policy to teach them landmark techniques (subclavians excepted) on live patients, though they are expected to know it for written boards.
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Really? Wow.
 
We learned landmarks for subclavian central lines. Only ever did one, it was a bloody mess. I can see why it's frowned upon. The medical director at the service I started at had a real dislike for IOs and actually forbid us from using them, even though the protocols were changing to make the EZIO the standard of care. She expected a central line on multi system trauma and arrests.

I was doing EJs on all my codes and as long as I was putting in a 16, nobody ever said anything.

But to t back on topic, for EMS, an IO should be the go to... Not an "I've done one in my career" procedure.
 
DEmedic said:
But to t back on topic, for EMS, an IO should be the go to... Not an "I've done one in my career" procedure.
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Completely agree. IO's aren't perfect, but are quicker and probably safer and more reliable than central lines, as least for people who don't do CIV's often.

I've done a handful of femorals.....those are the only CIV's I've done in the prehospital realm. They were situations where we had long transports and plenty of time and kind of a "why not" kind of scenario. Not the best justification for an invasive procedure.
 
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