> Could not disagree more. It's training issue; I can obtain internal 
> jugular access with a straight single pipe like a Wallace in under 10 
> seconds. There are three key points.
> 
> 1. Head down.
> 
> 2. Go low in the anterior triangle.
> 
> 3. Aim for the opposing femoral head. 
> 
> Guaranteed; venous puncture every time.

I'd add:
Go for the right side (straighter course, further from the lung and thoracic
duct)
Don't overrotate or overextend the neck
Take your finger off the artery (which seems to be the commonest reason for
failure)
Not guaranteed every time. Some patients have anomalous veins; some have no
vein; some have a vein that collapses with inspiration or the pressure of
the needle. There are certainly a few where it is impossible for anyone to
put a jugular line in. Ultrasound should identify these in a couple of
seconds. Not saying there's anything wrong with an experienced person
putting in the jugular line. However, if someone's not that slick with it
(as was suggested by the original post), there are other routes (each with
their own problems) that could also be considered.
My post was in reply to a post saying that the BIG was a lot faster than an
IJ line. If you can get a line in in 10 seconds, it isn't. If you can't, you
might want to think about a different technique. These days, US guidance
will prevent most of the failures, and speed you up in some cases. 

> Sorry Matt, don't agree. One of the many things I have 
> learned about trauma
> (whilst working in South Africa) was that the only vein you 
> can rely on to
> stay open is the subclavian. 

Doesn't always stay open. I've seen failures to put in subclavians, and have
scanned a few collapsed or absent veins. Also, veins that stay open when the
pressure's negative tend to suck in air. Not an absolute contraindication,
but a relative one. Down to individual skill with the approach. Advantage of
cut down is that it is the only way you can reliably cannulate a collapsed
vein. Reason for long saph at the groin is that it's probably the quickest
(in an unconscious patient) and easiest place to cut down. There are host of
reasons why you wouldn't put in a either a femoral line or a long saph cut
down, but they're both useful techniques to know. In cases where it's
impossible to use your favourite technique, it's worth having a couple of
backups, though- so femoral line, long saphenous cut down and IO needles all
have their place. 
My other point was that if you're not certain and you're in difficulty,
assess whether it's better to go in and risk complications or get someone
more experienced with the balance of a longer wait and higher complication
risk. If you make the call as soon as you've assessed that the patient is
sick enough to maybe need a central line; and start prepping while you're
waiting, the extra wait shouldn't be long.
As before, these days we've got ultrasound. Means you can tell which veins
will be easy before you put needle (or knife) to flesh.

> Another issue I want to clear up is I never said we were 
> using BIG/Fast-1 in
> trauma. The majority of IO attempts were made for arrests.

Now there I'm with you. In non traumatic adult arrests I go for the
subclavian myself (although with very few exceptions I remain to be
convinced of the benefits of giving anything IV in the early stages of an
adult cardiac arrest). I'd thought of the adult IOs for trauma as that was
what I'd heard about most (mainly from Israel)


> I agree that you may need an anaesthetic registrar there from 
> an airway
> point of view (although we never did in Jo'burg) but as 
> emergency physicians
> shouldn't we be capable of running a trauma?

Yes. My post was in response to a post suggesting that the IOs were useful
if there wasn't an A and E consultant present and (probably central) venous
cannulation was beyond the skills of the A and E middle grade. It is
entirely possible to get a job as an A and E middle grade with little
experience in central line insertion. If you can't get an A and E consultant
in fast enough (and some are neither resident nor living close to their
hospitals), you ought to have an anaesthetic registrar to hand.
As an aside, the term "running a trauma" is one we maybe ought to be moving
away from. Trauma is essentially a surgical disease- treatment takes place
in an operating theatre. All we do is to make an initial assessment of
severity of the trauma, make sure the patient is ventilating OK and speed up
the process of controlling the bleeding. The surgeon runs the trauma (in an
ideal situation), we serve as a support speciality (like anaesthetics and
radiology). No evidence that pre- op fluids benefit trauma cases; some
papers showing they worsen outcome. From time to time you have to accept
that you aren't the one who saves the patient.

Matt Dunn
Warwick


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