Prehospital Access of Central Lines

[NPO]

Do your protocols allow you to access central lines? If so, what do they say? Only in cardiac arrest, or when ever you deem necessary? Do they go into detail? Likewise, if not, do they say why and do they provide an alternative?

I recently brought up the subject of accessing central lines to my medical director because our protocols don't mention it.

He acknowledged that our protocols don't mention it, but encountered their use when justified in an emergency. He even went so far as to say that if a dialysis access line is all we have in a true emergency, then do what you have to do, but understand that the nephrologists will hate you for it.

I'd like to hear the input of others, and what you practice in regards to central lines.

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[SandpitMedic]

We don't play around with that stuff. I think of most procedures in emergency medicine this carries some hefty risks both during and after.

 

[Carlos Danger]

Do you mean med ports, dialysis catheters, and/or PICC lines?

I think the "only in an emergency" caveat makes good sense. These devices aren't rocket science and you probably aren't going to harm the device or the patient by accessing it. But....replacing them can be a real PITA and cost $$ so you aren't doing the patient or their doctors any favors by pulling it out or otherwise damaging it. But in a true emergency, no one is going to hate you for it.

Have someone (someone who actually uses them - probably a nurse - not just a buddy who thinks he knows everything) show you how to access them and don't be afraid of them at all if you need to use them.

 

[TXmed]

I think access of a true central line or PICC line in a true emergency is fine, i wouldnt necesarrily play around with the other stuff. their should probably be a protocol describing how to properly access it.

If you arent comfortable or confident then just do an IO. dont dwell on it too much.

 

[WolfmanHarris]

Under my directives I can access in an arrest or pre-arrest situation when IV access is unavailable. (Don't have to actually attempt just consider and rule out) However, since it's in my scope I can patch for an order to go ahead and access if the need arises outside of this.

 

[NomadicMedic]

We have a port/central access protocol, "only in extremis" or with a med control okay. We also have huber needles for ports. I've used a PICC for meds and fluid in the past.

 

[VentMonkey]

Do your protocols allow you to access central lines? If so, what do they say? Only in cardiac arrest, or when ever you deem necessary? Do they go into detail? Likewise, if not, do they say why and do they provide an alternative?

I recently brought up the subject of accessing central lines to my medical director because our protocols don't mention it.

He acknowledged that our protocols don't mention it, but encountered their use when justified in an emergency. He even went so far as to say that if a dialysis access line is all we have in a true emergency, then do what you have to do, but understand that the nephrologists will hate you for it.

I'd like to hear the input of others, and what you practice in regards to central lines.

It was left vaguely in our protocols for a reason (before this director took the helm), provider discretion. He basically answered your question in regards to its use.

This is in line with many other prehospital protocols as well, as others above have stated. If it's all you, it's all you have. Be sure that it is in fact all you have, make sure you're accessing the proper ports particularly with subclavians, and/ or the aforementioned dialysis catheters.

FWIW, huber needles for port-a-caths have to been one of the more simplistic central lines to access if properly trained.

 

[Handsome Robb]

We can use them if the patient is "in extremis". We also carry huber needles for the same scenario.


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[VentMonkey]

We can use them if the patient is "in extremis". We also carry huber needles for the same scenario.

I wish we had them---at least on CCT---and were properly trained to access them (as CCT paramedics). Ahhh yes Kern County, sooo forward thinking.

Do you mean med ports, dialysis catheters, and/or PICC lines?

Have someone (someone who actually uses them - probably a nurse - not just a buddy who thinks he knows everything) show you how to access them and don't be afraid of them at all if you need to use them.

I think he meant any, and all of the above. I think Remi has a good point in regards to them really not being that difficult, but it is best taught by nurses or others comfortable in accessing them frequently. Sublclavians and IJ's (med ports) work great as well, and are straightforward enough.

 

[VFlutter]

You would be surprised how much training we are required to be able access central lines in the hospital. There is a huge drive to reduce CLABSI. Even in a "clean" ICU they are so hard to avoid so I completely agree with not routinely accessing lines in the field, even though it may not seem like a big deal. Obviously in extremis is totally different.

 

[VentMonkey]

That being said, a patient in extremis (i.e., cardiac arrest) with an IJ in place seems the right candidate to forego IO access.

 

[TransportJockey]

PICC lines only in extremis and usually with orders. With teh general caveat of aspirating 10cc of blood and discarding. But considering we carry EZ-IO, and it's preferred and almost as quick, the times our crews use a PICC is very very rare.
We rarely see other types of central veinous access. And we don't carry huber needles, so implanted ports are a big nono for us.

 

[NomadicMedic]

We have a PICC/port inservice once a year and have to demonstrate clinical competency on the port manikin. As almost everyone else mentioned, I'd rather just drill an IO and be done with it.

 

[NPO]

We have a PICC/port inservice once a year and have to demonstrate clinical competency on the port manikin. As almost everyone else mentioned, I'd rather just drill an IO and be done with it.

Problem is, we don't have EZIO, just the manual ones.

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[NomadicMedic]

Problem is, we don't have EZIO, just the manual ones.

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Twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist, "damn." Twist, twist, twis...POP.

 

[NPO]

Twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist, "damn." Twist, twist, twis...POP.

Yes yes. But we don't have a high success rate with them. I'm one for two. I know most other medics struggle too

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[VentMonkey]

Problem is, we don't have EZIO, just the manual ones.

Says you.

 

[VentMonkey]

Yes yes. But we don't have a high success rate with them. I'm one for two. I know most other medics struggle too.

It is most unfortunate both sides don't have EZ-IO's, bougies, or X-series (I am about done with those E-series we have; very outdated), but I digress...

 

[NPO]

It is most unfortunate both sides don't have EZ-IO's, bougies, or X-series (I am about done with those E-series we have; very outdated), but I digress...

I think we're moving away from them. Now that we've broke the ZOLL wall with our new PCR program. I'd be happy with an X series though.

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[VentMonkey]

I think we're moving away from them. Now that we've broke the ZOLL wall with our new PCR program.

Speculation or proof? If cold hard facts, PM me.