Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – Aggressiveness and the New Cutdown with Leon Boudourakis, MD. EMCrit Blog. Published on September 17, 2014. Accessed on December 4th 2022. Available at [https://emcrit.org/emcrit/aggressiveness-and-the-new-cutdown/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: September 17, 2014
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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It’s aggressive, sure… But, I’m going to reach for My EZ IO and get access just as quick, and maybe quicker since I’ve done that about a dozen times. I still am open to learning something new and having more tools will give me something when I have a patient with busted upper and lower extremities.
Jose Diaz PA-C
agree-IO is the way to go for stat tube/meds. Not fantastic for massive transfusion.
Not too aggressive if everything else is failing and pt is crashing. With that being said, big vessels are usually easy to hit with landmarks or US. The only delay with US for me is time to put on sterile cover probe (10 secs) as typically fired up and ready to go with sick pt coming in. I can see how this technique can be very fast, but with rarity of application, may be more time consuming than regularly practiced methods especially in morbid obese.
yep except in the hands of a truly experienced trauma surgeon like Deb Stein
Yep it is aggressive in my opinion. I get about three or four patients a year in the ICU…some trauma and some medical that I just can not get access. Either the wire will not feed or something. In the ICU usually I am not as pressed as in the ED unless they are really crashing. I like the IO approach the more and more I see it used in codes and ED’s as well as the field by EMS. I will usually try a line first. Honestly I have only had to go the IO route once and that… Read more »
One more comment I have to make is this. I have watched a number of residents try and try to get access using ultrasound in the groin during a code. Usually this is a challenge. If they are overwt, then feeding the wire is a bit of challenge that is sometimes a fail. In the era of aggressive cpr it is rare that we stop compressing the chest so most people shy away (at least in internal medicine) from placing a subclav in a code. Where do you ED folks usually go when the traumas come in… Groin? Subclav? IJ?… Read more »
Learned this trick from Aurelio Rodriquez during a stent at Shock Trauma back in the 90s. Its as close to instantaneous access as you can get. Flail potential is practically non existent.
Thanks for sharing this technique Scott. In the perspective of life and death, I don’t think it is too aggressive. It is nice to read about this procedure for two reasons: 1. It might be the solution to a specific patient we will encounter. When everything else fails or is unavailable. 2. It is a nice example of thinking outside the box and come up with a “clear-cut” solution to a serious problem. I see three difficulties: 1. Due to anatomical variation it might be difficult te locate the vein. http://www.minnisjournals.com.au/_images/articles/pdf/article-pdf-0094.pdf On the other hand, it is unlikely that you… Read more »
I appreciate everyone’s thoughts. The above-picture was my first one supervised by Director of Trauma at Shock Trauma when I was a fellow. It was my first; it literally took <15 from time of asking for knife to blood flowing into the patient. This patient had multiple, and failed, attempts at access by IJ by an attending trauma anesthesiologist, bilateral subclavians, and groins. He had an IO in – but he needed rapid transfusion. Peripheals were impossible. I would tell you that since that time – I have practiced more and become quicker. Well – it's so ridiculously easy that… Read more »
forget picts; video, video, VIDEO! we want a good example of a proper Local Wound Exploration as well. come-on, Trauma man.
Thanks for your reply with the additional info and insights. I agree with your comments. In the described setting, I can imagine this could be a life-saving procedure. Therefore will share this with my collegues and trauma surgeons (and tweet about it of course to share it with our fellow FOAMies). Thanks for sharing and Scott: thanks for posting!
Cheers,
Hans
One more thing – how deep do you cut? You cut past the epidermis and dermis into sub cutaneous fat. If you hit muscle you are too deep…
We would cut through dermis and dissect rapidly with fingers through the fat to the fascia and there she was.
Why is the catheter placed distally? It seems like it would more likely become obstructed by the valves within the venous system that prevent backflow.
Dillon, I think you may have the picture reversed as did I initially. The patient’s head is to the right so line enters proximal to venous cutdown.
You’re right. Thanks.
Thanks for adding another tool to the toolbox. Much appreciated. I just want to remind everybody that not all IO access is equal. Proximal humerus = 5x greater flow rate than proximal tibia. You can easily blast 5L/hour of crystalloid into a patient with a pressure bag using a proximal humeral IO (not that we would ever do that in trauma, of course.) I know some have expressed concerns about hemolysis if blasting PRBCs into an IO, but thus far, to my knowledge, those concerns are only theoretical, and those who have looked for evidence of hemolysis haven’t found it.… Read more »
Back to the future, sort of… the saphenous cutdown was the standard when I was training and we had to “prove” that femoral lines via Seldinger technique was as good or faster. This study was done during my residency at Northwestern: http://www.ncbi.nlm.nih.gov/pubmed/8135430 and consisted of 78 patients randomized to cutdown or femoral line. Time to infusion 6.65 minutes for cutdown, 4.56 min for femoral line. If you read the article, also look at the time to completion of procedure (much longer for cutdown) and rates of failure to infusion (6 in cutdown group; 3 in line group, pts transferred rapidly… Read more »
nice, v. nice
I did a groin cut down +10yrs ago. Good thought to go a bit distal. Same approach in upper arm if pelvis rogered? Prob too much clockwork…..
No don’t do this technique in the arm. the Anatomy is not analogous
I think some of you may be missing the point. This technique is easy and only requires a knife and pickups. Worry about tying off the distal vein after (or just clamp it). You simply cut until it the leg bleeds, grab the vessel and insert the catheter. No clamp no retractor no thinking no dissection. This technique is actually faster than a traditional placement of a central line. I wouldn’t hesitate to use this technique in the setting of a patient who desperately needs access and resuscitation for trauma. My patience for waiting for access in a patient in… Read more »