RE: Central Line Protocols

[Robert Cole <EMCOLERS@adaweb.net>]

I guess I should have been clearer, I meant to dispute the implication that
medics would do a central line instead of an EJ if an EJ was available.

In response to the rest of the comments:

Time on scene doing traditional access (with a guide wire, etc) would be
significant, However we use 16 gauge "longdwell" over the needle caths,
simplifying the procedure.  In the ER the MD would normally pass the guide
wire and proceed from there.  By the way , we normally do Sub clavians, or
IJ's, local preference only.  

Smart medics and nurses would of course consider scene /transport times,
etc. But they must also anticipate clinical course, also known as the "big
picture".  And I know the Air medical environment is cramped, I know (former
Army medic as well. I do have some flight experience as well, mainly fixed
wing, and military)

However if you have a patient who you cant get traditional IV access on due
to vascular collapse, medical or trauma, there is a good chance (generally
speaking here, I know there are exceptions)  that a central line is your
only access.  Now if you have the adult IO available, then that would be a
route of choice (especially in pre-code situations) We do not have the FAST
system here.

Question: Are the Fast system capable of infusing blood products? If not,
then that is one advantage of central lines over fact one system, if your
service carries blood products.

Central lines may not be appropriate in your setting, but there are settings
it would be appropriate.  Our local Air medical services ( I am not a member
so I am strictly providing an informed outsiders view) is often the only ALS
responder to many parts of rural Idaho, and transports frequently exceed the
30 minute mark. In addition they are often used for non trauma scene
responses.

We use central lines in the 911 setting, usually in vascular collapse,
codes, occasionally accompanied by prolonged transport times.

Robert S. "Steve" Cole
Paramedic, CCEMTP
Education Department
Ada County Paramedics 
208-375-7079
emcolers@adaweb.net

"...A mind stretched with new ideas never regains its former shape"


-----Original Message-----
From: wcemt@terraworld.net [mailto:wcemt@terraworld.net]
Sent: Thursday, December 27, 2001 10:10 PM
To: flightmed@flightweb.com
Subject: RE: Central Line Protocols


Mr Cole,

Thank you for your input, however I don't 
think the question was "are medics smart 
enough to do central lines".  As a flight 
paramedic and a former Army medic I have 
been trained to place central lines and many 
other procedures far more and am quit 
comfortable performing them.  However, the 
question that was asked was in regard to the 
use of central lines, by a helicopter flight 
crew based in a large metropolitan area 
(Atlanta, GA) and was specificly directed at 
scene flights involving trauma pt's.  First 
of all you need to take into consideration 
that trauma patients need a surgeon more 
than they need a central line, so wasting 
time on scene is not the best course of 
action.  Secondly, you need to factor in 
that most helicopters have a very limited 
area in which to work and many do not allow 
adequate access to the femoral region, 
leaving the subclavian site for central line 
placement.  Further more with a flight time 
that will usually be 30 minutes or less to a 
major trauma center, why take a chance on 
complicating a situation with an invasive 
procedure like a central line when you can 
acheive the same results with a good large 
bore IV in the AC or EJ, or you can place a 
substernal IO with far less complications 
and much faster.  It should also be pointed 
out that the F.A.S.T. substernal IO device 
that was mentioned in the original question 
is capable of adequate fluid resuscitation, 
with the following average flow rates:
gtt to gravity - 30ml/min or 1800ml/hr
gtt w/ preasure bag - 125ml/min or 7500ml/hr.

As a member of an education department, I am 
suprised that you have overlooked these 
details as most medics are smart enough to 
look at the "big picture"

Wesley Copeland Sr., MICT, NREMT-P, CCEMT-P
Flight Paramedic

> We do central lines in the field, most 
medics are smart enough to do them if
> an EJ is not available.
>  
> 
> Robert S. "Steve" Cole 
> Paramedic, CCEMTP 
> Education Department 
> Ada County Paramedics 
> 208-375-7079 
> emcolers@adaweb.net 
> 
> "...A mind stretched with new ideas never 
regains its former shape" 
> 
> -----Original Message-----
> From: Wesley Copeland Sr., MICT, NREMT-P, 
CCEMT-P
> [mailto:wcemt@terraworld.net]
> Sent: Thursday, December 20, 2001 9:40 AM
> To: flightmed@flightweb.com
> Subject: Re: Central Line Protocols
> 
> 
>  I would have to agree with your doc's 
regarding their concerns over central
> lines in the field.  Why risk causing the 
complications with a central line
> when you can get an EJ?  Given, EJ's can 
cause problems too, but
> comparatively they are safer, faster and 
easier than a central line.
>  
> Wesley Copeland, MICT, NREMT-P, CCEMT-P
> LifeNet of the Heartland
> 
> ----- Original Message ----- 
> From: Paranurs536@aol.com 
<mailto:Paranurs536@aol.com>  
> To: flightmed@flightweb.com 
<mailto:flightmed@flightweb.com>  
> Sent: Wednesday, December 19, 2001 7:26 PM
> Subject: Re: Central Line Protocols
> 
> I'm a flight nurse with Emory Care in 
Atlanta.  We've just merged into the
> Emory system and are a part of  LifeNet 
(RMH).  Right now, all our Docs are
> being very conservative and we're only 
doing sternal IO's which doesn't get
> us past the volume issue when our critical 
traumas need volume.  We're
> working on them and hopefully we will be 
doing central lines shortly.  Are
> you guys using the sternal IO's?  They're 
great for med administration (RSI,
> etc.) even low volume drips but (with my 
experience) don't infuse volume
> fast enough.  We have access to cadaver 
labs but the Docs don't seem very
> enthused about us actually perfoming the 
procedure in the field.  They come
> up with all kinds of excuses for us not to 
do them ... wasting time on-scene
> starting lines, complication rate, etc.  
Any suggestions?  Be safe! 
> 
> Francis Peed, RN, EMTP 
> Flight Nurse 
> Emory Flight (Atlanta) 
> 
> 


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