EMCrit Podcast 75 – Live Show # 2

The 2nd EMCrit Live Show was so much fun!

Here are some of the things we discussed:

Should we be using the femoral route for central lines?

Minh Le Cong posed that question.

Seth (@mdaware) has a great post with a talk by Matt Pirotte

All of the evidence is there.

Who to lyse in submassive PE?

Casey Parker of Broome Docs fame asked this one.

Who needs Cath after Cardiac Arrest?

Karen from down under asked this one. Luckily I have a post just waiting to go with the answer.

Should we be using NIPPV for ARDS or Pneumonia?

Andy Buck (@edexam) chimed in with this one.

What should you do if your cath lab refuses to take therapeutic hypothermia patients?

Rebecca, a PA Student, wrote in with this question.

Alexander a prehospital and ED doc from Spain wrote and asked:

Should we be using CPAP or BiPAP for Preoxygenation?

and finally, the Rogue Medic wants to know why I don’t talk about

Not needing to Intubate once DSI has been used?

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Comments

  1. Faiza Shahbal says:

    Enjoyed the podcast.Thanks so much..You make it so easy.

  2. Scott, great show. Thank you. The CME link for this show doesn’t seem to be up on the CME site.

  3. Joseph B says:

    Definitely disagree regarding the fem lines in a crashing patient!

    I think most peoples experience would support the relatively high rates of PTX during subclavians in extremely hypovolemic patients. I have noticed on ultrasound the SC vein is often completely collapsible during the respiratory cycle giving you about a significant chance of missing the vein and hitting SCA or lung in this setting.

    Conversely most of us have done hundreds of crash fem lines – and very few have personal experience with retroperitoneal bleeds. I think experienced practitioners who stay below the inguinal ligament should have a very low rate of this complication. Infection rates high absolutely – stabilize the patient then get’em out. The icu resident needs to have some fun too.

    jb

    • Minh Le Cong says:

      JB, I interviewed Dr Mathew Pirotte this morning about this topic. He gave a prizewinning talk entitled why you should never / rarely insert a femoral line. I am going to publish the podcast soonbut we have a great discussion and whilst he and Scott are clearly fans of the SCV lines, even Mathew admitted he still resorted to femoral access on occasions,
      we discuss the evidence base for central line complications. I agree with you for resuscitation its a useful route of access. Its not perfect but as you point out neither is SCV access. and for that. matter neither is IO access. Mathew and I discuss that too on the next PHARM podcast

    • Joseph,

      In experienced hands the rate of pneumo is infintesimally low. My own rate is <0.1%. The “subclavian” distal to the angle of the clavicle is collapsible; this is the standard site of ultrasound guided subclavians. This is not truly the subclavian. The SCV under the medial 1/3 of the clavicle is not collapsible. Even in an exsanguinated patient with complete collapse of the SVC, the SCV is still patent.

      The thing about retro-p bleeds is you will not know you caused them in most patients, they self-resolve. The skin entry site of a properly placed femoral line is at the inguinal ligament, the entry is above the ligament. Going lower risks getting into one of the branches of the fem vein.

      If you are using ultrasound, knock yourself out with femoral lines. Blind/crash femoral lines are the worst combination, IMHO.

  4. I completely agree with Scott regarding the femoral line comments.

    As a surgery chief resident, I have seen several complications from others (usually medicine, but also er and my surgery peers) putting in femoral lines during urgent/emergent situations….retroperitoneal bleeds, and arterial pseudoaneurysns. I’m very comfortable with the anatomy… So much so that I won’t put in a femoral without an ultrasound myself! not because I’m incapable of doing it, but because I’ve been in there for groin dissections and I know the anatomical variations, and I hate the VERY morbid complications.

    So for me if a patient is crashing, I generally put a subclavian line in.

    For a coagulopathic patient, a patient should get one like and one line only…. IJ ultrasound placed line.

    Now… The problem is so many people now are uncomfortable with subclavian lines which is really a disservice to our patients.

    My favorite femoral line is the GSW to the belly where in the OR all the product is spilling into the belly cuz the iliac is blown off. :)
    Now let’s get realistic. How many people are REALLy comfortable with subclavian lines?

    • Manrique says:

      I agree with Leon. Our approach to this subject and what we teach our residents in my institution is to go to the SCV in unstable (sometimes IO), US guided IJ if coagulopathic or not in a hurry and very rarely a femoral line (just don’t like the complication rate even when US guided). We try to make sure they’re comfortable with the SCV access.

  5. Thank you for the opportunity to ask questions and the forum for a bunch of people to contribute to the discussion.

    .

  6. arinne says:

    I’ve had a run of patients recently who’ve been nightmares for vascular access. Most were dialysis patients, and I ended up putting in femoral lines (under ultrasound) in two of them in order to stay away from their dialysis access. I was wondering how other people approach this – will you place a subclavian on the same side as a fistula? How about a how about an IJ on the same side as a subclavian tunneled line, or vice versa?

    • so this is a very good use of femoral lines. Ultrasound guided, full sterile and you are good shape. I try to stay away from SCV in HD-potential or HD patients as you may burn that arm for access.

      • Oh and yes I think it is fine to put an ultrasound guided IJ in a patient with a SCV but be careful many of the tunnel caths that look like SCV are actually IJ.

  7. Don Diakow says:

    Excellent Podcast Dr. Weingart! Boussignac CPAP question: Polypharm OD pt resp min rate of 60/min and Hypermetabolic. GCS about 4-5 and your only 10 mins from the ER .Local protocol doesn’t allow RSI this close to the ER ( I was thinking an awake intubation with Ketamine) but we couldn’t get his Sat’s above 91 92 with an NRB. Coarse crackles to all lung fields due to aspiration. Would you, could you use the Boussignac CPAP for better FIO2? What has everyone’s experience been with gastric insufflation from the Boussignac CPAP with decreased GCS?

    • We would use CPAP on this pt in preparation for intubation. When using CPAP on a pt with altered mental status, you must watch them like a hawk and not use this as a substitute for intubation, but instead, a bridge.

Trackbacks

  1. […] I asked Mr EmCrit himself, Dr Scott Weingart and check out his response on EmCrit Live show #2 […]

  2. […] his heart is struggling.I asked Scott Weingart this question and he answered it on his recent Emcrit Live #2 show – Scott reckons he would take the lytics, but the evidence suggests the benefit is about improved […]

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