IVC Placement

[Timmy]

G’Day Guys,

Just a quick questions in regards to placement of IVs during Trauma or Medical Emergencies. Anatomically speaking, were is the best place to start large bore IVs?

I was recently in a situation were the patient was going down hill quiet quickly, I popped two bilateral 18g into the cubital fossa but when the anaesthetist arrived he wasn’t happy about having the IVCs placed there and proceeded to place another two 18g into the lateral aspect of the patients lower arms. The patient needed a dedicated line for an infusion and another line for fluids but didn’t really need four bungs.

On rapid assessment he had great basilica/cephalic veins in the cubital fossa so I just went for them…

[BushyFromOz]

The anaesthetist wasn't happy as the cubes are large veins and have been essentially wasted by a smaller cannula than is required. The fact that he whacked another 2 in further down probably indicates he had pretty good veins, and the combines flow rate of 4x18g i imagine met the anaesthetists needs.

Start from the bottom and work your way up mate. I usually go for a patent 18/16 in a lower arm before and then look to try and duplicate that, but i try and avoid using the cubes if i can.

[JakeEMTP]

With Bushy on this. I prefer to start IV's in the lower inside forearms if possible, especially on trauma pt.'s. My mrs., who is a circulating nurse in the OR, says most trauma surgeons prefer not to have IV's in the AC's because of the way pt.'s must sometimes be manipulated. Having an IV in a "fold" (for lack of a better term, hey, I just got up) can interfere with the flow of fluids sometimes due to the position some pt.'s must be placed.

For me, I like to start them in the forearm because it doesn't hurt the pt. as much and it is easier for me to keep an eye on it. The vein's are usually pretty straight and will hold a 18/16 in most cases.

[Richard B the EMT]

Having an IV in a "fold" (for lack of a better term, hey, I just got up) can interfere with the flow of fluids sometimes due to the position some pt.'s must be placed.

Back when New York State EMTs were allowed to transport patients with flowing IVs, some joker Instructors used to refer to this as "Tip of Thumb to Tip of Nose Syndrome", corrected by straitening the arm.

(Forgive me, spellcheck still not functioning)

[hatelilpeepees]

Another reason you do not start up high, is that you have to remember that patient may be in the hospital for days or weeks. By putting one in both arms, at the AC, you potentially ruin the chance to use the distal veins if one or both ACs get infected or infiltrate. If you have veins big enough for a 18 or 16 in the hand or forearm, that would be preferrable to start as low as you can, so that the next line will not have to be a central line. Most research no longer advocates dumping several liters of IV fluid in patients any more (In the old days we would put 6-8 bags in a trauma patient). If 2,000 cc's doesnt fix it, they are probably bleeding to death so all you are doing is turning their blood pinker.

[firemedic37]

Having an IV in a "fold" (for lack of a better term, hey, I just got up) can interfere with the flow of fluids sometimes due to the position some pt.'s must be placed.

This in fact is a huge problem during transport, most trauma pt's just don't lay still and not move their arms when they are in pain or having problems breathing. I rarely start them in the AC, they are a pain. They stop flowing when they bend their arm and if you have them on an IV pump then it beeps at you the entire time.

Think about the majority of the life threatening trauma pt's that we have, they mostly are younger people experimenting with something. They are some of the easiest pt's to start an IV on and you can very easily establish a 16/18 G in the hand or inner forearm. I start most of my IV's inner forearm, pt's tend to pick at them less too.

The only reason that they may of started new lines were to ensure that they did not become clamped off during surgery since they needed infusions and fluids to maintain life.

[fiznat]

I started lines in the AC all the time, I think it's a great spot to go. I found that there is almost always good access there, it causes less distress to the patient (compared to more distal locations), and there is oftentimes a fair amount of connective tissue surrounding the vessels so that they don't move around when you introduce the needle.

If the anesthesiologist thinks two 18g IVs isn't enough, he/she should probably think about placing a central line instead. Same goes for any patient who is going to be a long-term intensive care admit who will need large bore access for the duration. Anesthesiologists are famous for being quite particular about these things though, so no surprise he/she had some sort of issue with what you did. I wouldn't worry about it. Two 18+ gauge IVs in a fairly proximal location like the AC is the standard of care for peripheral lines pretty much anywhere you go.

[island emt]

I think I've only started lines in the AC twice this year. One was a donorcyclist with both hands raw meat and a FX radius.ulnar, & the other a cardiac arrest.. The normal medical pt gets a 22 or 20 in the hand or if needed an 18 in the forearm.

Starting up at the AC is lazy and wasting a lot of valuable venous real estate.

What happens when you start high and they infiltrate? Then what? EJ or IO?

had a chemo pt last week with nothing for veins in either hands or arms, but a tremendous access in his left foot.

After getting a look from the receiving nurse at the ER she poked him half a dozen times before giving up and admitting that our good flowing 18 in the foot was the right solution.

[paramedicmike]

Agree with what's been posted so far. I'm also with Island EMT. Some of the best IVs I've gotten on people have been in the legs. So long as they can handle the access there it's a good place to stick.

[fiznat]

What happens when you start high and they infiltrate? Then what? EJ or IO?

There are still 3 other extremities.... Also, just because you have a proximal infiltrate doesn't mean you can't still go distal. How do you think the blood still circulates when you blow a vein? There are tons of collaterals, and big ones too. I agree it wouldn't be my first choice to go more distal, but it's a bit much to suggest the distal arm is vascularly dead after you puncture the cephalic vein.

Edited August 12, 2011 by fiznat