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Key Points

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  • The ability to access the central venous circulation is an imperative skill for emergency physicians and is often needed for life-saving measures.

  • The central venous circulation can be accessed both above and below the diaphragm. The site should be chosen based on reason for access as well as body habitus and pattern of injury for trauma patients.

  • Although the overall complication rate for central line placement is low for experienced providers, serious complications may occur.

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Indications

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The most common reason for placement of a central venous catheter in the emergency department (ED) is for resuscitation of the critically ill medical or trauma patient. Medical patients may require central access for large volume fluid resuscitation, central venous pressure monitoring, IV pressors or other medications caustic to the peripheral veins (dextrose, hypertonic saline, total parenteral nutrition), transvenous pacing, or emergent dialysis. Trauma patients most often require central access for large-volume resuscitation with both fluids and blood. Central access is also used in ED patients with difficult peripheral IV access.

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Contraindications

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Central access should not be attempted when peripheral access is obtainable and no other indication is present. Central access should be avoided at sites with overlying cellulitis or other anatomic abnormalities such as extensive trauma that may cause distorted anatomic landmarks. Known coagulopathy is an absolute contraindication to subclavian vein cannulation (noncompressible site) and a relative contraindication for internal jugular and femoral cannulation. Finally, patients must be able to cooperate during the procedure by remaining still. An uncooperative patient is a relative contraindication that may require sedation before the procedure.

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Equipment

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Most of the equipment needed to perform central venous cannulation can be found in commercially available central line kits (Figure 3-1). Kits include povidone-iodine swabs, guidewire introducer needle, J-tip guidewire, multiple 5-mL syringes, 1% lidocaine, 22- and 25-gauge needles for local anesthesia, #11 blade scalpel, dilator, central line, and silk suture on a cutting needle.

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There are multiple types of central lines. In general, 1 of 2 types is used in the ED (Figure 3-2). A triple-lumen catheter is used for patients who require multiple different medication drips or when there is difficulty obtaining peripheral venous access. A sheath introducer (Cordis) catheter is shorter and wider and is used for introducing transvenous pacers, Swan-Ganz catheters, and for rapid infusion of fluid and blood products in the hypotensive patient. These larger catheters can achieve flow rates up to 1 L/min.

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Figure 3-2.

From left to right: A. sheath introducer kit (Cordis) with dilator. B. Triple lumen catheter. C. triple lumen dilator.

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Procedure

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