> I can't imagine why you might want to do a central line
> prehospital, Mike; I
> rarely see them being inserted in A&E these days, except for
> the "long haul"
> resus case that's lining up for ITU.
This (the A and E, no pre- hospital) may warrant a rethink- there is
considerable and increasing evidence that resuscitation in A and E improves
outcomes (and reduces costs). While you may be able to resuscitate
aggressively without the need for a central line, some departments have
limited consultant availability after midnight, and it might be better for a
registrar to place one if they're running a case without supervision.
On pre- hospital central lines, it's not so much length of training as
ongoing experience. There aren't many indications for central line
insertion, and I'd reckon your typical advanced paramedic (or whatever term
is being used) would be lucky to place more than a couple a year. Then you
get into the question of maybe they should be placing them electively in
ITUs for the practice (say a weeks ITU placement every 6 months), but that
opens a whole new can of worms with regard to ethics of training. Although
for an inexperienced operator, ultrasound guided line placement is probably
going to be quicker and safer.
> Well, quite. Subclavian access is just as quick and usually
> just as easy.
Although not as safe of course (especially when you're an ambulance ride
away from the resus room).
> Femoral lines can be
> done easily, although I have found on a few occasions that I
> have cannulated the artery as it is
> so close, and by the time you are looking for that sort of
> access there often isn't much
> blood pressure left to differentiate them!
Again, ultrasound guided line placement.
> In the unconscious
> I now do a quick cut down to be
> sure I am in the right place.
Are you talking about cut down onto the long saphenous at the groin or
cutdown to enable central line placement? Personally I think the long
saphenous cut down is a pretty simple technique- it's certainly rapid, safe
and easy, and maybe deserves to be taught more than it is.
Matt Dunn
Warwick
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