Central Lines Prehospitally

[Aidey]

For the record, I don't think there is a single person here saying they want central lines to be added to their protocols, so it is unclear who you are addressing in your post.

 

[truetiger]

I think they have a place in EMS, I couldn't tell you how many times I've wanted to start one on a transfer patient because the sending facility is running a pressor dose of dopamine on a septic patient through a peripheral site...they simply won't place central lines even in patient's that are in bad need of one. I think its leasable, with proper training, to allow central lines in transfer situations in which the ED is improperly treating the patient. In fact, there's quite a few air and ground cct services that do this, that is respond to the po dunk facility and fix the $&@# up before leaving.

Do they have a place on a scene call or in an ambulance? No way. If your patient is sick enough you think they warrant a central line, then why not drill them? IO = central access.

 

[Rialaigh]

I think they have a place in EMS, I couldn't tell you how many times I've wanted to start one on a transfer patient because the sending facility is running a pressor dose of dopamine on a septic patient through a peripheral site...they simply won't place central lines even in patient's that are in bad need of one. I think its leasable, with proper training, to allow central lines in transfer situations in which the ED is improperly treating the patient. In fact, there's quite a few air and ground cct services that do this, that is respond to the po dunk facility and fix the $&@# up before leaving.

Do they have a place on a scene call or in an ambulance? No way. If your patient is sick enough you think they warrant a central line, then why not drill them? IO = central access.

I could see this warranted. CC interfacility transport gets on scene and the patient is about to bite the dust, your looking at an hour or an hour and a half transport time. I could completely agree with allowing these medics to start a central line, confirm correct tube size and placement, correct drip dosage, etc etc over 30 minutes to an hour to stabilize the patient in the ER prior to transporting, maybe even call the receiving doc to see what meds should be started prior to going en route to increase survival chances of the patient...

this is about the only application I see it even remotely beneficial

 

[Clipper1]

For the record, I don't think there is a single person here saying they want central lines to be added to their protocols, so it is unclear who you are addressing in your post.

Am I supposed to single out someone? I don't feel that is necessary for the content of this discussion. Is there a reason you feel I should single out someone?

My post was just asking some of the things to consider. Our Paramedics do insert central lines and these are the same questions are being asked. I also know of a few other agencies which insert central lines. If you can not come up with an adequate reason for the insertion of central lines in the field then maybe it is time to consider moving on to what is more acceptable in this age where getting back to time sparing techniques to allow for effective compressions or minimally invasive procedures are being advocated.

 

[Clipper1]

I think they have a place in EMS, I couldn't tell you how many times I've wanted to start one on a transfer patient because the sending facility is running a pressor dose of dopamine on a septic patient through a peripheral site...they simply won't place central lines even in patient's that are in bad need of one. I think its leasable, with proper training, to allow central lines in transfer situations in which the ED is improperly treating the patient. In fact, there's quite a few air and ground cct services that do this, that is respond to the po dunk facility and fix the $&@# up before leaving.

Do they have a place on a scene call or in an ambulance? No way. If your patient is sick enough you think they warrant a central line, then why not drill them? IO = central access.

I could see this warranted. CC interfacility transport gets on scene and the patient is about to bite the dust, your looking at an hour or an hour and a half transport time. I could completely agree with allowing these medics to start a central line, confirm correct tube size and placement, correct drip dosage, etc etc over 30 minutes to an hour to stabilize the patient in the ER prior to transporting, maybe even call the receiving doc to see what meds should be started prior to going en route to increase survival chances of the patient...

this is about the only application I see it even remotely beneficial

If this is the situation to where you believe the patient is too unstable to transport without more lines or a central line, you call your medical director and allow an MD to MD discussion to take place. Is the patient crashing when you pick them up? Not every septic patient gets a central line. If they do it is to monitor CVP. If you are not monitoring CVP during transport and the patient is stable otherwise there might not be a need to put the patient at further risk with a central line until in the other facility.

And, the alterative in transport or prior could also be an EJ. But, if the patient is crashing the IO is also a good alternative.

You also should know that many times the kits for prehospital central access are short lines or catheters. They are not the standard central lines used in the hospitals. You would not need an xray to confirm placement. This means they will not be used for monitoring CVP and they must be removed to another line to be placed.

Placement of a regular central line can be tedious and must have an xray. Once in, you are not going to have much room for error and you don't just push it in if you don't feel you got it right.

 

[truetiger]

Hmm central line only to monitor CVP? What about pressors? The local hospitals we frequent like to use dopamine as their pressor of choice for anything. Why make a septic patient tachycardic and irritate the heart? Sepsis isn't a pump problem, so you'll need to adequately fluid resuscitate them and take care of the pipe problem (decreased SVR). Levophed is a popular choice, and needs a central line for administration.

Short catheters? Are you referring to a cordis? I don't know of any "short" central line catheter. A triple lumen can be administered through the cords.

 

[Bieber]

No, it is not physically impossible to accomplish. But that is not the same thing as being practical (feasible = practical).

Picture the process of donning sterile gloves, gown, and mask, opening a sterile CVC line kit, cleansing the site, prepping the line, placing the line, flushing all 3 ports of the line, and placing a sterile dressing, all without breaking sterility. Remember, if at any point, anything that should be sterile touches something that is not-sterile, you start over. That means no touching anything at any point during the process, including the patient. And this is all done at the scene, because there is definitely no doing this while moving towards the hospital.

Now think about the time involved here. Even if everything goes well, you are looking at a minimum of 5-10 minutes of prep time alone. In the hospital, the process of placing one of these can easily take 30 minutes or more. And that is by people who do them all the time and have a lot more room and help than you have in the ambulance.

The places where I've done these (and I would guess, most other places that do these prehospital), we simply didn't bother with all that. You open the kit and prep your equipment, put on some sterile gloves, clean the site, and make the stick. You can justify this occasionally with the fact that in some patients in some situations, the need for central access outweighs the risk of infection. But I think you are talking about a really, really small population here, and in most cases we are just exposing the patients unnecessarily to the risk of a difficult procedure in the field and introducing pathogens directly into the central circulation. Not good.

The other thing is indication. Why do you need a central line, anyway? The most common indication for them in the hospital is in patients who are getting multiple infusions (pressors, abx, etc) or caustic meds (chemo, etc) that irritate peripheral veins.

Lastly, CVC's are quite often not easy, even in the best circumstances. US definitely makes them easier and safer, but now you are talking about adding another significant expense and training burden just to do an occasional CVC?


For a program that does a lot of transports of really sick patients, AND has more experienced than average clinicians, AND has a good way to train on them regularly, I think it may make sense to have CVC's in their skills repertoire. But you are mostly just talking about helicopter and some ground CCT programs.

Bu generally speaking, CVC's are just impractical to do in EMS, and very rarely necessary. Especially with the advent of the IO devices we have now.

Like I said, I agree that they are not practical for EMS, nor does there seem to be a tremendous need for them in our setting. The challenges to actually performing them, and performing them correctly, however, seem to have more to do with us than anything else.

 

[Rialaigh]

If this is the situation to where you believe the patient is too unstable to transport without more lines or a central line, you call your medical director and allow an MD to MD discussion to take place. Is the patient crashing when you pick them up? Not every septic patient gets a central line. If they do it is to monitor CVP. If you are not monitoring CVP during transport and the patient is stable otherwise there might not be a need to put the patient at further risk with a central line until in the other facility.

And, the alterative in transport or prior could also be an EJ. But, if the patient is crashing the IO is also a good alternative.

You also should know that many times the kits for prehospital central access are short lines or catheters. They are not the standard central lines used in the hospitals. You would not need an xray to confirm placement. This means they will not be used for monitoring CVP and they must be removed to another line to be placed.

Placement of a regular central line can be tedious and must have an xray. Once in, you are not going to have much room for error and you don't just push it in if you don't feel you got it right.

I know a lot of critical transport occurs between tiny outlying facilities and large level 1 centers. The facility that I do clinical work at and frequent often has a 9 bed ER, one doc in the whole hospital between 6p-6a, a 20 bed med surge and a 6 bed critical care neither of which are ever full. I know when we get a bad patient and call for a chopper to take them (or ground transport on cloudy, windy, rainy, full moon, or any other reason days...) if the patient is in real bad shape the ER doc wants them out as soon as possible and generally says "just get them the %#$ out of here. When the critical care transport team shows up its their show, our ER doc wants nothing to do with the patient, if you want blood we will get if for you, if you want meds we will pull them for you, its your show, you tell me what you want and we get it for you and then you get them the hell out. Any MD to MD communication would go like this "my team tells me the patient is XYZ and has ABC and needs EFG, what about HIJ" and the ER doc at our tiny facility would say "do whatever you want just get them out of here".


I feel comfortable with the critical care transport near us, they are excellently trained, well equipped, calm, and ready to do anything. I would be perfectly okay with them placing a central line, getting their drips in order, starting blood, and then moving the patient out. I would feel much better with them starting a central line then our ER doc saying "call the CRNA in (45 minutes minimum) and have them place the line" most of our ER docs wont place central lines, some of them hate intubating and will call in the CRNA at night to do that...


There are plenty of small facilities where this is a reality, I am comfortable with the critical care transport near us doing ANYTHING that they want, they are well trained...

 

[chaz90]

I think an ED Doc that won't place a central line or intubate needs to reevaluate their career choice. The country does need more family practice physicians, few of which are ever called on to do either of those procedures.

 

[truetiger]

See that's the problem. These docs are not ER docs. They are family practice physicians either moonlighting or by some turn in their career ended up in the ER. It's pretty bad when most of the medics and nurses have a better idea than they do.

 

[Rialaigh]

I think an ED Doc that won't place a central line or intubate needs to reevaluate their career choice. The country does need more family practice physicians, few of which are ever called on to do either of those procedures.

I agree but this isn't isolated to near me. Many many small town hospitals that get all the trauma and unstable cardiac patients first in to "stabilize" have these types of docs. The critical care teams that have the ability to act in part as a physician greatly increase the chances of these patients making it alive to an appropriate facility whether it be straight to an ICU or straight to surgery.

 

[usalsfyre]

I think an ED Doc that won't place a central line or intubate needs to reevaluate their career choice. The country does need more family practice physicians, few of which are ever called on to do either of those procedures.

The problem is most of these guys are FM docs or moonlighting residents.

 

[VFlutter]

Just to clarify I think the original intent of the thread was 911 EMS medics (Non CCT) placing central lines in the field. Although CCT/Flight medics or RNs placing central lines in the hospital setting is a related topic it is really a totally different argument.

In my opinion critical patients can be placed into 3 categories in relation to central lines...
A) Absolutely need a CVC for early goal directed therapy
B) May be beneficial; not necessary, but would be convenient
C) Not indicated

I think we have a bias towards thinking our patients are in group A when in reality the vast majority are in group B or even C. For many of the scenarios people have purposed it sounds like a central line would be been beneficial but not absolutely necessary. Then you again have to weigh the risk vs benefit.

Up until just recently a central line with CVP monitoring was the standard of care for all septic patients. We are starting to move away from that and towards non-invasive measures. Some MDs won't place invasive lines until they get a few doses of antibiotics and have a therapeutic draw.

When a MD is refusing to place a central line do you just assume that they are incompetent to do so? Or do you have a conversation as to the reason behind why they are refusing? Is it possible they have a better understanding of the situation then you do? I have no doubt that some MDs in rural ERs may be unwilling due to competence, and rightfully so. Central line placement is not a benign procedure that you should be doing if you have not done one since your residency years ago.

A Cordis usually refers to a single lumen large diameter (8-9fr) central line. They not really used much anymore outside of trauma and CT surg. You can float a TLC, PAC, or TVP wire down them.

 

[Rialaigh]

Just to clarify I think the original intent of the thread was 911 EMS medics (Non CCT) placing central lines in the field. Although CCT/Flight medics or RNs placing central lines in the hospital setting is a related topic it is really a totally different argument.

In my opinion critical patients can be placed into 3 categories in relation to central lines...
A) Absolutely need a CVC for early goal directed therapy
B) May be beneficial; not necessary, but would be convenient
C) Not indicated

I think we have a bias towards thinking our patients are in group A when in reality the vast majority are in group B or even C. For many of the scenarios people have purposed it sounds like a central line would be been beneficial but not absolutely necessary. Then you again have to weigh the risk vs benefit.

Up until just recently a central line with CVP monitoring was the standard of care for all septic patients. We are starting to move away from that and towards non-invasive measures. Some MDs won't place invasive lines until they get a few doses of antibiotics and have a therapeutic draw.

When a MD is refusing to place a central line do you just assume that they are incompetent to do so? Or do you have a conversation as to the reason behind why they are refusing? Is it possible they have a better understanding of the situation then you do? I have no doubt that some MDs in rural ERs may be unwilling due to competence, and rightfully so. Central line placement is not a benign procedure that you should be doing if you have not done one since your residency years ago.

A Cordis usually refers to a single lumen large diameter central line. They not really used much anymore outside of trauma. You can float a TLC, PAC, or TVP wire down them.

If your transport time is under an hour or an hour and a half (even longer likely) then I see 0 9-1-1 patients that fall into category A.

There is absolutely no early goal directed therapy requiring a central line prior to the patient being evaluated by a physician, If we are talking strictly 9-1-1 response I see no reason to ever place one without having a critical care mobile team there taking control of the patient for an extended transport time.

 

[Clipper1]

Hmm central line only to monitor CVP? What about pressors? The local hospitals we frequent like to use dopamine as their pressor of choice for anything. Why make a septic patient tachycardic and irritate the heart? Sepsis isn't a pump problem, so you'll need to adequately fluid resuscitate them and take care of the pipe problem (decreased SVR). Levophed is a popular choice, and needs a central line for administration.

Short catheters? Are you referring to a cordis? I don't know of any "short" central line catheter. A triple lumen can be administered through the cords.

Cordis (brand name) could be used but not all that useful. It is also a single lumen.

You are not going to be placing multi lumen central catheters in the field. The EMS agencies which do place central catheters in the field will just use a longer large bore catheter which can be a 10 - 14g.

Yes central lines (multi lumen) are used to monitor CVP. If you are not going to monitor CVP during transport, many times a PIV will give adequate flood. A second PIV is always advisable for transport which can administer meds.

If a physician writes for norepinephrine then he or she should know it should be given via central line.

Raileigh

I feel comfortable with the critical care transport near us, they are excellently trained, well equipped, calm, and ready to do anything. I would be perfectly okay with them placing a central line, getting their drips in order, starting blood, and then moving the patient out.

If the team is well trained and has the time to do a real central line and wait for x-rays, reposition and suture, then great. Since many CCTs don't have the ability to carry blood, the formalities of the hospital would be to get the appropriate labs first. Hopefully the physician has already done that.

Some EMS teams get annoyed when they transport flight or specialty teams such as pedi or neo because these teams are well trained and might spend 1 - 4 hours inserting lines and stabilizing before transport back. They usually drop off and will be called back later. Few stick around to watch the teams. But, these teams also spend hours training and continuing their education perfecting their skills in the hospital and must do x amount of CL insertions per quarter. This would probably be difficult for many perhospital EMS based CCTs where getting enough intubations is a challenge.

One of the reasons ER doctors want the patients out is bed availablity. If the patient is not transferred to a larger facility quickly they could lose the ICU bed. If the patient gets admitted to the small town hospital's ICU, transferring out is a :censored::censored::censored::censored::censored: due to getting someone to accept the patient. The exception is usually children since there is a standing agreement for them.

Which teams are you talking about? North Carolina? A few of their teams are very impressive but the ones I am familar with are a mix of different health care providers and are hospital based.

 

[Clipper1]

I agree but this isn't isolated to near me. Many many small town hospitals that get all the trauma and unstable cardiac patients first in to "stabilize" have these types of docs. The critical care teams that have the ability to act in part as a physician greatly increase the chances of these patients making it alive to an appropriate facility whether it be straight to an ICU or straight to surgery.

No they do not "act as a physician".

Everything they do can be within their scope of practice and they act under the protocols of their medical director (physician) and the directors (more physicians) of a specific unit.

This applies to whoever and whatever title they have behind their name on the transport teams.

But, their whole knowledge base and experience will be larger. One or two impressive skills alone does not save the patient. If you insert a central line (not just a single lumen catheter) you should have the ability to use CVP monitoring and titrate all medications effectively.

 

[usalsfyre]

If this is the situation to where you believe the patient is too unstable to transport without more lines or a central line, you call your medical director and allow an MD to MD discussion to take place.

And say what exactly? Order him to place a central when he's obviously not comfortable with the procedure? Or we leave the pt in a place where he's sure to die vs possibly dying in transport? Good way to be a pt advocate...

Is the patient crashing when you pick them up? Not every septic patient gets a central line. If they do it is to monitor CVP. If you are not monitoring CVP during transport and the patient is stable otherwise there might not be a need to put the patient at further risk with a central line until in the other facility.

Pressors are a pretty good reason for a central line. Especially when you talk about taking the show on the road where peripherals can get pulled all too easy. Not to mention CVP is not an accurate target for fluid resus (citations to follow when I get home)

 

[VFlutter]

Cordis (brand name) could be used but not all that useful. It is also a single lumen.

You are not going to be placing multi lumen central catheters in the field. The EMS agencies which do place central catheters in the field will just use a longer large bore catheter which can be a 10 - 14g.

Yes central lines (multi lumen) are used to monitor CVP. If you are not going to monitor CVP during transport, many times a PIV will give adequate flood. A second PIV is always advisable for transport which can administer meds.

http://www.youtube.com/watch?v=6KHM-IVF5Ek
Here is a video showing the 3 most common types of central lines: Triple lumen, cordis (introducer), and trauma.

I believe the one you are referring to is the trauma line, most commonly made my Arrow. It is a short, wide, single lumen catheter similar to a Cordis but shorter and does not have the ability to accept other lines. The Arrow Trauma Central Line kit is what KCM1 uses.

 

[Rialaigh]

No they do not "act as a physician".

Everything they do can be within their scope of practice and they act under the protocols of their medical director (physician) and the directors (more physicians) of a specific unit.

This applies to whoever and whatever title they have behind their name on the transport teams.

But, their whole knowledge base and experience will be larger. One or two impressive skills alone does not save the patient. If you insert a central line (not just a single lumen catheter) you should have the ability to use CVP monitoring and titrate all medications effectively.

What I meant by this is outside of life saving traumatic complex surgical procedures a lot of well trained critical care transport teams can and will do about anything a ER physician does. They will place chest tubes, they will place central lines, they do surgical assisted intubation and some do trach's.

They pretty much function as a physician under another physicians license, their scope of practice and what they can do is so much higher then a regular paramedic or nurse that they fall much more in line with what ER physicians will do.

Which teams are you talking about? North Carolina? A few of their teams are very impressive but the ones I am familar with are a mix of different health care providers and are hospital based.

All of my experience (working at several area hospitals and then flying patients out from scene) is with Med Center air through CMC in Charlotte, NC. Every team they have ever sent (especially pediatric specialty teams or perfusion teams) seem to have been excellently trained, well equipped, ready to do anything, and have good communication and working relationships with their doctors and ours. When they show up our docs generally turn all care over to them, if they want to extubate the patient, change every drip, and do a surgical airway our doc steps out of the way and says "your patient, I trust you, take care of them and get them on out of here".

 

[Clipper1]

And say what exactly? Order him to place a central when he's obviously not comfortable with the procedure? Or we leave the pt in a place where he's sure to die vs possibly dying in transport? Good way to be a pt advocate...

Two physicians should come up with a viable alternative. Hopefully your MD knows your scope of practice and the meds you carry. Having contact between the two higher levels of care for a discussion about YOUR concerns is much better than you just running off with an unstable patient. There might actually be a decent alternative for meds. Not all meds are just used the way your current protocols read. Don't assume all doctors at these smaller hospitals are incompetent. Sometimes if they are reminded of things to do by another physician, they get it together quickly.