II. Approach: Peripheral Access

  1. Peripheral IV Access (default initial line)
    1. Gauge 18 or larger is preferred
    2. Initial Resuscitation with fluids
      1. Fluid infusion via 18 gauge peripheral IV is faster than via a triple lumen central catheter
    3. Medication administration including antibiotics
    4. Intravenous Contrast administration (reliable 18 gauge IV needed for CTA, PE studies)
    5. Initial Vasopressors may be used peripherally if reliable large bore IV (until central access is obtained)
    6. Allows for venous lab samples on placement and later
      1. Requires wasting part of sample, and then Flushing line
  2. Intraosseous Access
    1. Rapid landmark based placement with multiple available sites (e.g. proximal tibia, Humerus)
    2. Emergent Vascular Access for Resuscitation when peripheral IV cannot be immediately placed
    3. Allows for infusion of most fluids and medications including Vasopressors (but not Sodium Bicarbonate)
  3. Midline Venous Catheter (Ultrasound-Guided Antecubital Line)
    1. Alternative to central venous access when standard peripheral lines are difficult
    2. Extravasation is more common with deep brachial vein IVs
  4. Rapid Infusion Catheter (RIC Line)
    1. Converts a 18-20 gauge peripheral IV into a large bore line (8 Fr)
      1. Seldinger wire is threaded through peripheral line and peripheral IV is removed
      2. Skin is nicked at IV entry site and dilator is threaded over wire and through skin
      3. Catheter is threaded over wire and into vein and wire is removed
    2. Allows for high flow rates via peripheral line
    3. Risk of destroying peripheral vein by threading it with too large of a catheter

III. Approach: Central Access

  1. See Central IV Access
  2. Background
    1. Central Lines are sewn in place and typically more secure than peripheral lines which may be dislodged
    2. Internal Jugular Veins are preferred central access points
      1. However, in Resuscitation, consider femoral lines which are out of way of Resuscitation efforts
      2. Convert femoral lines to other sites in first 48 hours
  3. Central Line Types
    1. Triple Lumen Catheters
      1. Best for infusing multiple medications (including Vasopressors)
      2. Slower infusion rates (under pressure) than 18 gauge peripheral IVs
    2. Introducer Catheters
      1. Largest bore of the central catheter options offering high infusion rates
      2. Weingart recommends bypassing side port with commercially available product
    3. Hemodialysis Catheters
      1. Large bore catheter (12-13 french) with 2 ports

IV. References

  1. Weingart and Swaminathan in Herbert (2021) EM:Rap 21(4): 5-7

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