Morning Report: 3/5/2013

Thanks to Dr. Lau for today’s Morning Report!

The Case:

Unknown male BIBEMS after being dragged by street cleaning vehicle for unknown distance, “lost vitals in ambulance bay”.  Right side of chest visibly deformed (close flail chest).  After definitive airway management, still no access.  Tried multiple peripheral IVs, femoral central line and subclavian line all failed.  IO drill is out of battery. What do you do?

Venous Cutdown

Indications:

–       No absolute indication – when all else fails (central lines, IOs, mucosal administration of required medication…)

–       Tend to be used in small children where access is difficult

–       Hypovolemic shock – vessel collapse

Contraindications:

–       if any other less invasive alternative exists

–       coagulopathy

–       vein thrombosis

–       overlying cellulitis

Anatomy:

Greater Saphenous Vein

–       usually done 1cm proximal and 1 cm medial to medial malleolus

–       can also go in the medial thigh 3-4 cm distal to inguinal ligament

Basilic Vein

–       preferred site for upper extremity – 1 to 2 cm lateral to the medial epicondyle on the anterior surface of upper arm

Technique:

–       Knowledge of local anatomy very important of course

–       Place tourniquet proximally

–       Local anesthetic if pt is awake

–       Skin incision made perpendicular to course of vein – very important to not incise vein as it can be very superficial

–       Blunt dissection with curved hemostat in direction parallel to course of vein with tips down

–       (may use tissue spreader to keep field open)

–       Isolate vein from adjacent tissue

–       Either use hemostat to elevate vein or pass folded suture under vein (cut suture in 2 to have one prox an one dist – tie distal suture)

–       Insert angiocath directly into vein

–       Or nick vein with scalpel (DO NOT transect vein) and insert cordis with dilator directly into vein (you can also insert IV catheter directly in emergency)

–       Tie proximal suture, close wound and dress

Videos:

• http://www.youtube.com/watch?v=AHuJZHvTNGE
• http://www.youtube.com/watch?v=y8NFo5kJbWk (weird musical version but on real patient)

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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