Possible arterial line??

[pamedic983]

I had an uneventful call with a chief complaint of hypertension this afternoon. Nothing out of the ordinary really: I boarded the BLS truck, went en route to the local hospital, did my assessment, put her on the monitor, started a line, drew labs, etc. etc. and then we were there. What I found odd was the color of the blood in the tubes. It was rather bright and not that dark red I usually see. I put the line in the lateral half of her left forearm approximately 2 inches distally from her elbow because I felt what I thought was a nice vein right there. I got a nice flash and the cath advanced without trouble. After drawing labs I attached a saline lock and it flushed without difficulty. All of my procedures were carried out with no problems. I was just curious if it were possible to have an artery that close to the surface of the skin in that location of her arm. I thought I would have seen/felt a pulse if I had been in an artery.

Any thoughts or suggestions?

 

[triemal04]

It's possible. From the location you describe you could maybe have hit the radial artery. While it's not that easy to do, starting an arterial line by accident can be done, especially if you go to deep, or have a very small/emaciated pt.

Usually you'll know though; when the IV tubing (or lock if you used that) starts filling up with blood repeatedly (in these weird spurts too ) might want to start thinking about where you stuck them. Doesn't sound like you did though.

 

[VentMedic]

Yes it is possible to cannulate an artery there as it can be near the surface on some patients but with the hypertension one would hope you notice a significant flow when you went to connect or back flow with a possible pulsation in the tubing before your fluids started running.

The other possibility is the SvO2 might have been high. In that case your uneventful hypertension warranted closer assessment for issues that would decrease O2 extraction. The HTN can increase cardiac output which will affect the SvO2. Running a patient on a level of higher FiO2 (hyperoxia) may also increase the SvO2.

 

[pamedic983]

Didn't notice anything

I didn't notice any pulsations or increased flow when I attached my saline lock. I was just surprised by the color of the blood.

I didn't give the pt any supplemental oxygen as she denied any complaints of dyspnea, her SpO2 was 98% on room air, and we were only minutes from the hospital. I think her hypertension was more an initial false reading by her automatic cuff that caused her anxiety and then really did cause her mild hypertension. I never recorded anything over 140 systolic.

 

[VentMedic]

I didn't give the pt any supplemental oxygen as she denied any complaints of dyspnea, her SpO2 was 98% on room air, and we were only minutes from the hospital. I think her hypertension was more an initial false reading by her automatic cuff that caused her anxiety and then really did cause her mild hypertension. I never recorded anything over 140 systolic.

What signs/symptoms did the patient describe/present with?

There are several reasons for increased SvO2.

 

[pamedic983]

She dialed 911 because her automatic cuff read 215/174 during her routine morning check. Her only symptom was heartburn, but she had a history of acid reflux disease and was being treated for it. She denied chest pain, difficulty breathing, headache, nausea, dizziness, blurred vision, and any recent illness. She called her doctor's office and they told her to call 911. She took one nitro tab prior to my arrival. When I got her, my initial B/P was 140/90. Sinus tach around 107, no ectopy, strong regular pulse, respirations 22, SpO2 98%, BGL 131mg/dl, skin pink, warm, dry, GCS 15, lungs clear, abdomen soft non-tender, no complaints of pain.

 

[VentMedic]

Her only symptom was heartburn, but she had a history of acid reflux disease and was being treated for it.

Isn't that what the Washington DC EMT(P)s said?

Female
Heatburn
Hx of HTN
Nitro

12 lead?

Anyway, I hope you did Google SvO2 to see what I was getting at. Often when we draw blood on Flight, Specialty, ED or anywhere in the hospital, very red or very dark venous blood may give us another clue for something else to investigate for the differential.

 

[pamedic983]

Yes, I did Google what you said and ask my coworkers about SvO2 and I will continue to educate myself about it. I appreciate the feedback. I did do a 12-lead and found nothing abnormal there. The nurses in the ER just kind of shrugged me off when I mentioned the color, but I was still curious.

 

[VentMedic]

Thank you for clarifying that.

Just to let you know since I am now a "young" middle-aged woman, for my first MI, I would be in complete denial. I will talk myself out of every symptom. I will be pis*** at whoever called EMS. And, I will probably argue with everything you say. However, if you are professional enough, you will get the point across to me that some diagnostics and treatment will be necessary so I might as well STFU.

 

[boingo]

I can imagine the poor crew that responds to vent's MI....Lord help them! LOL

 

[medic417]

I can imagine the poor crew that responds to vent's MI....Lord help them! LOL

As much as I like Vent I have to agree.

 

[VentMedic]

As much as I like Vent I have to agree.

No worries.

I live in an area where I will get 5 - 8 Paramedics, graduates of the finest medic mills Florida has to offer, responding to me.

 

[benkfd]

I had an uneventful call with a chief complaint of hypertension this afternoon. Nothing out of the ordinary really: I boarded the BLS truck, went en route to the local hospital, did my assessment, put her on the monitor, started a line, drew labs, etc. etc. and then we were there. What I found odd was the color of the blood in the tubes. It was rather bright and not that dark red I usually see. I put the line in the lateral half of her left forearm approximately 2 inches distally from her elbow because I felt what I thought was a nice vein right there. I got a nice flash and the cath advanced without trouble. After drawing labs I attached a saline lock and it flushed without difficulty. All of my procedures were carried out with no problems. I was just curious if it were possible to have an artery that close to the surface of the skin in that location of her arm. I thought I would have seen/felt a pulse if I had been in an artery.

Any thoughts or suggestions?

As I see many have told you that, yes this is possible. I have done this myself only mine was in what I thought was an AC vein. No pulsation, did think it was an odd color to the blood. One of the nurses in the ER noticed that there was blood pulsating in the saline lock. Go figure!

 

[Sasha]

No worries.

I live in an area where I will get 5 - 8 Paramedics, graduates of the finest medic mills Florida has to offer, responding to me.

And you would probably bring them all to tears!

 

[maxwell]

Very common question. To check if you've started an art line, load up a 10mL flush with NS (or whatever you have) - and attach it to the hub of the angiocath (or whatever you're using). If it's an IV you'll either get NO blood return, or a slow leak. If you're in an artery, you'll get a pulsation of blood into the syringe. (Much safer than perfusing all over the floor, no?). D/r the color of the blood...drugs to weird things to the color of blood! And, hell, if you're in an artery, get a blood gash34r:!

 

[VentMedic]

And, hell, if you're in an artery, get a blood gash34r:!

...except that EMS trucks usually don't carry an iSTAT or heparin.

However, if this happens in the hospital, on Flight, CCT or Specialty transports, I'll put a transducer on it and use it for blood draws or BP monitoring. Brachial a-lines will need closer monitoring for distal perfusion.