Vascular Access in Trauma
11
CONTENTS
11.1 Summary . . . 137
11.2 Background . . . 137
11.3 Management . . . 137
11.3.1 In the Emergency Department . . . 137
11.3.1.1 Management Guidelines in Acute Vascular Access . . . 138
11.3.1.2 Which Route is Recommended for Acute Vascular Access? . . . 138
11.3.1.3 Technique in Acute Vascular Access . . . 139
Further Reading . . . 140
11.1 Summary
Make sure you are familiar with the tech- niques for vascular access before the trau- ma case arrives.
Use the technique for vascular access in which you are most experienced.
Do not hesitate to start simultaneous expo- sure of several different veins.
Do not forget the cubital fossa as a possible site for vein exposure.
11.2 Background
Optimal management of a trauma case includes fast resuscitation, diagnosis, and immediate start of treatment. In most injured patients, two large peripheral intravenous (IV) lines are sufficient to provide adequate initial treatment and volume replacement. In rare cases of greater trauma and in unclear cases this might be insufficient and sev-
eral (sometimes central) IV lines are needed. In bleeding shock with collapsed and empty veins, inserting peripheral IV lines are difficult. For these reasons some techniques for alternative ac- cess should be included in the armamentarium of all physicians who take part in the management of trauma cases. In many hospitals the general sur- geon on call is in charge of the trauma care and is thus responsible for providing adequate vascular access.
11.3 Management
11.3.1 In the Emergency Department Today most trauma patients admitted to emergen- cy departments already have one or two peripheral IV cannulas that were inserted by the paramed- ics.
After securing airways and respiration, the sur- geon on call checks the patient for possible ongo- ing and previous bleeding and estimates the blood losses. Besides being part of trauma management, this information is also necessary for planning the need for vascular access. According to our rou- tines all trauma cases are subjected to immediate infusion of 2 l of Ringer’s acetate. If this volume has a positive effect on tachycardia and the pa- tient’s general condition, and the patient is not ob- viously bleeding externally, the total possible blood loss will usually not exceed 15–20% of the total blood volume. For these patients two large- bore IV cannulas (2 mm in diameter) are almost always enough for the initial volume replacement.
The order in which the volume replacement should
be done and in what proportion the Ringer’s,
blood, plasma, packed cells, or dextran should be
given varies between hospitals and should, of
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Vascular Access in Trauma138
course, be in accordance with local prescriptions and routines.
11.3.1.1 Management Guidelines in Acute Vascular Access Always start by checking that the patient has two functioning IV cannulas. If they are functioning but are too small in caliber – <1 mm in diameter – a guide wire can be used to replace them with larger ones. Insert the guide wire in the thin can- nula, pull it out over the guide wire, leave the guide wire in the vein, and insert a new wider IV can- nula over the guide wire. Occasionally the skin perforation is too small and needs to be dilated.
The cannula replacement should be performed simultaneously with another person’s attempt to place IV cannulas in other sites. Patients with greater ongoing bleeding, such as a patient who is bleeding through a fresh wound dressing within a minute, as well as those with a history that indi- cates larger blood losses, almost uniformly require several IV cannulas. Short and large-bore cannu- las permit the highest possible volume flow and if there is space available on the arms and neck more peripheral cannulas are warranted. Make simulta- neous attempts at several different sites – for ex- ample, in the external jugular vein and in the veins on the hands. If this is not successful there are three alternatives:
1. Surgical exposure of veins in the cubital fossa or on the leg
2. Percutaneous catheterization of the femoral vein
3. Central venous catheterization in the subclavi- an vein or external and internal jugular vein The best choice of these three alternatives is not always obvious and should be based on factors such as the part of the patient’s body that is in- jured, the responsible trauma surgeon’s experi- ence, the urgency and the type of fluid that needs to be infused. The following general advice might be helpful irrespective of the technique chosen:
Never place an IV cannula in extremities in- jured by crush or burn.
Avoid extremities with fractures.
If larger vascular injuries are suspected, includ- ing pelvic fractures, which are frequently asso- ciated with extensive venous damage in the pel- vis, IV lines should be placed above as well as
below the diaphragm to ensure that adminis- tered fluid reaches the central circulation and is not lost on the way because of vascular inju- ries.
Another possibility for acute access is an interos- seous cannula. This, however, is not described in this chapter.
11.3.1.2 Which Route is Recommended for Acute Vascular Access?
Some 20 years ago surgical cutdown was the meth- od of choice in trauma because most surgeons used this method electively. At that time it was routine and surgeons could generally insert and fixate a large-bore IV line within just a couple of minutes. Today this experience is generally lack- ing and trauma care according to Advanced Trau- ma Life Support, for example, recommends the second alternative listed above, catheterization of the femoral vein. The reason is probably that cath- eterization of the femoral vein is technically easier to perform for someone surgically inexperienced than surgical cutdown or central catheterization.
In many countries, including the United States, catheterization of the jugular and subclavian veins is more widespread, in particular among anesthe- siologists.
If cutdown is chosen, most textbooks recom- mend the greater saphenous vein at the level of the median malleolus as the best, most easily ac- cessible, vein. This technique is identical with the one used in stripping a varicosed greater saphe- nous vein. The disadvantage is that it is rarely possible to draw blood from the greater saphenous vein at the level of the ankle joint even if the catheter has an intravasal position. This is due to the vein valves and also to the fact that periph- eral veins are often collapsed. The patients are frequently in shock as a consequence of severe bleeding. With longer catheters placed in the greater saphenous vein drawing of blood samples is sometimes possible thanks to confluent vein branches. The function is tested by rapid injection of 10–20 cc of saline.
If the patient has pelvic injuries or the best
veins have been consumed in previous varicose
vein surgery or bypass operations, the cubital fossa
is a very good alternative. These veins are also lo-
cated closer to the heart. In some cases, branches
139
to the greater saphenous in the groin can also be used, especially if the surgeon is experienced in surgical exposures in this area.
11.3.1.3 Technique in Acute Vascular Access
The cutdown technique is described in the Tech- nical Tips box and displayed in Fig. 11.1. Note that the technique is identical to that used for implant- ing permanent venous infusion ports and other central venous catheters. A surgeon experienced in such procedure can perform a cutdown and catheterization rapidly and effectively. For the same reason, cutdown is probably an underesti- mated and underused alternative.
Central catheterization is performed in Scandina- via mostly by anesthesiologists and with great skill. This alternative for access in trauma has the disadvantage of long catheters with a relatively small caliber, making rapid infusion of large vol- umes difficult. Direct puncture in the neck region can be difficult and even dangerous in an anxious and hypoxic patient. In a patient wearing a stiff neck collar it is almost impossible. A central ve- nous catheter allows objective measurement of central venous pressure (CVP), but its value in managing acute trauma is hard to appreciate, and CVP rarely needs to be measured in the emergen- cy situation. The recommendation is therefore to save central catheterization until the most impor- tant emergency care is over.
For catheterizing the femoral vein, a Seldinger technique is used. Make sure that suitable sets for catheterization and different catheters are at hand.
Previously described problems during cannula- tion in the lower extremities are, of course, also valid for this technique.
In summary, surgeons managing trauma cases ought to be familiar with one or several different techniques for acute vascular access. This should be practiced beforehand, prior to the arrival of the trauma case in the emergency department.
TECHNICAL TIPS
Vascular Access in Trauma
Technique for exposing the greater saphenous vein
a)1. Scrub and drape a 10u10 cm large area ante- rior to the medial malleolus.
2. If the patient is awake, infiltrate a local anes- thetic.
3. Make a 3 cm-long transverse incision anteri- or to the medial malleolus.
4. Expose the greater saphenous vein by blunt dissection on a length of 2 cm, and protect the saphenous nerve.
5. Pull two absorbable 2-0 sutures under the exposed vein with a clamp.
6. Ligate the vein as far distally as possible with a distal suture. Do not cut the ends of the suture.
7. Place a knot in the proximal suture but do not tie it.
8. Make a transverse cut in the vein with an eye scissor. Do not make it too small. Dilate the venotomy with the tip of a small clamp (mos- quito).
9. Insert a catheter a few centimeters while applying slight traction on the distal su- ture. Tie the proximal suture around the catheter for fixation. If tunnelation is consid- ered, make a second separate incision a few centimeters distally and pull the catheter under the skin before inserting it into the vein (Fig. 11.1).
10. Connect the infusion system and close the wound with a nonresorbable single suture.
Do not forget to fix the catheter with a suture to the skin.
a) An identical technique can be used to expose and cannulate the cubital vein.
11.3 Management
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Vascular Access in Trauma140
Further Reading
Klofas E. A quicker saphenous vein cutdown and a bet- ter way to teach it. J Trauma 1997; 43:985–987 Waisman M, Waisman D. Bone marrow infusion in
adults. J Trauma 1997; 42:288–293
Fig. 11.1.
