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32 Trauma Team Decision-Making
271
Clinical Practice Guidelines (CPGs)
CPGs are algorithms [24] for the major possible trauma scenarios and attempt to synthesize the best available evidence
and the best available judgment into safe and efcient strategies to advance patient care (Fig.32.4).
But the decision to transfer a patient out of the trauma bay
toward more denitive care is not easily informed by simple
or even multivariate scores, and the specic decision points
within CPGs still depend on the analysis of data and individual judgment (Fig.32.4). Data points used to inform the
decision arrive in real time, can rapidly change over time,
and can be unreliable. The decisions themselves, even if
based on perfect data, are complex. While all clinical decisions are made under conditions of uncertainty, decisionmaking in trauma often occurs under conditions of extreme
uncertainty, making judgment and experience big factors in
the determination of strategy.
The science of decision analysis applies explicit and
quantitative methods to analyze decisions made under conditions of uncertainty. Figure32.5 explores the decision to
move a patient from the trauma bay to the CT scanner or to
the operating room, a frequent challenge encountered by
TTLs. While all the inputs into this decision and the conse-
quences of this decision are difcult to map out in an embedded gure, the exercise of doing so can help decision-makers
gain some depth of understanding about the decision-making
process. The raw data to calculate the probabilities for the
chance nodes of this decision tree already exist in the literature. Decision-making tools in the future may be able to harness the data collection, computing, and analytic power of
new information technology tools not only to populate the
probabilities but also to modify these probabilities and
inform clinical decisions based on accumulating data in real
time.
Regardless of what decision-making strategy is used,
TTLs must take an active role in the decision-making process to progress the trauma patient through resuscitation and
toward denitive management. Even incorrect decisions will
provide information that will shape subsequent decisions.
Decision-making is a dynamic and iterative process that
requires close observation and continuous renement. For
example, if a patient’s blood pressure drops as they are being
readied for CT and outcome probabilities change, the
decision- making process and the team should be agile
enough to rapidly re-direct them to a waiting operating room.
The team would have been observing the patient intently
during the transfer process, watching for new information,
Fig. 32.4 Clinical decision-making under conditions of uncertainty—
integration of anatomic data (chest X-ray (CXR), pelvic X-ray (PXR),
FAST), and physiologic data on response to resuscitation (arterial blood
gas (ABG), vital signs) guides movement down the clinical pathways
and to the ultimate destinations (shown in light green)
272
Abdominal trauma
Death in CT
Base
u1
u2
u3
u4
u5
CT
p1
Unstable to OR
p2
Arterial bleed
p3
No intervention needed
p4
N. Gawad et al.
OR
Angioembolization
excess -5, FAST +
OR
Fig. 32.5 The anatomy of a decision—lessons from decision analysis.
This is the age-old decision about whether to take a transiently responsive trauma patient to CT or to the OR.While critical decisions in the
trauma bay are often made based on judgment and pattern recognition,
every major decision can be broken down into its component elements,
and analyzed based on the best available probability and outcomes data.
The probabilities “p” will be modied based on emerging physiologic
data and will in turn inuence the proportion of patients reaching each
p5
p6
p7
keeping options open, and modifying the plan accordingly.
As long as TTLs and trauma teams are keenly aware of
emerging data and the effect of decisions, a wrong decision
is better than no decision.
Trauma Team Leadership: Translating Decisions into Action
There are three essential aspects of trauma team leadership:
continuously gathering and processing information from an
array of sources to create a clear vision about the priorities of
care, making decisions based on this information, and inspiring and coordinating the trauma team to enact these decisions. The process of transforming raw data to clear vision
and nally to concerted action is examined in Endsley’s
exploration of the concept of situation awareness, which he
denes as “the perception of elements in the environment
within a volume of time and space, the comprehension of
their meaning, and the projection of their status in the near
future.” This process, which involves taking disjointed data
elements regarding the status and dynamics of a situation,
integrating them into a comprehensive picture, and then predicting and addressing future developments, is a fundamental responsibility of the TTL.To do this well, the TTL must
promote an environment of open and clear communication,
and must be able to step back from the resuscitation enough
to achieve and act on situation awareness [25].
Death in OR
Major complication (including missed TBI)
Full recovery
health utility “u” state. In this example, indicators of shock (base decit) or active bleeding (FAST exam) may make p1 and p2, and their
outcomes prohibitively higher than p5 and p6, supporting a decision to
go to the OR.Currently, TTLs weigh these probabilities subconsciously,
but information technologies may eventually be able to provide and
adjust probabilities in real time, to increase the objectivity of decisionmaking. Square = decision node, circle = probability node, triangle=outcome node
It is helpful for both inexperienced and experienced
trauma teams to be aware of all relevant data as these data are
collected, and periodic summaries of clinical status can
reduce uncertainty and anxiety, and inspire condence in
team leadership considerably. It is also extremely helpful for
the team (and the TTL) to communicate the anticipated
threats and the rationale for decision-making, even if the
decision may subsequently be revised. A decision-making
rationale statement may be something like this:
This is a 32-year-old man involved in a motorcycle crash
with transiently responsive hemodynamic instability, pos-
sibly due to intra-abdominal hemorrhage or pelvic frac-
ture based on our FAST exam and pelvic X-ray. We have
secured his airway and have good IV access, with O nega-
tive blood infusing. CT is ready for us. Our priorities are
to log roll him, place an orogastric tube and a foley cath-
eter, and prepare him for transfer to CT within the next
5min. I am still worried about ongoing bleeding, and we
should keep an OR on standby.
This statement claries the TTL’s thinking and priorities
and brings the team in on the decision-making process creating a shared mental model (Chaps. 4, 5, 6, 8), thus allowing
the team to simultaneously prepare for multiple possible scenarios. Synthesizing gathered information into a plan of
action, rather than simply summarizing, is an essential way to
32 Trauma Team Decision-Making
273
prepare a complex resuscitation and multidisciplinary team to
transition seamlessly between therapeutic alternatives.
The style of leadership that engages the vision and talents
of team members and unies them behind a singular purpose
has been described by Collins in a study of highly successful
companies. Collins’ research team noted that companies that
were able to negotiate adversity to achieve dramatic growth
consistently had leaders with a “paradoxical” combination of
great personal humility and strong professional will to
achieve sustained results. The researchers considered this
combination to be at the pinnacle of the hierarchy of leadership attributes, and called it Level 5 leadership. The ability of
a trauma team to acquire and share knowledge and to seamlessly deliver complex, integrated, life-saving care may
depend on a similar style of open and humble leadership and
an unwavering focus on process and goals [26].
Forward Communication andHandover
One of a TTL’s essential roles is to pave the way forward for
the patient and the team. Forward communication should
commence even before a patient’s arrival, or very early during
a patient’s assessment. Vital time is lost, and the duration of
shock prolonged, if this role is neglected. Forward communication starts with the automatic alerts of all essential services,
including emergency medicine and surgical teams, radiology,
lab, blood bank, OR, and ICU.However, as therapeutic priorities become clearer, the TTL must move beyond the automatic
alerts to customize the response. This may mean ensuring that
the CT scanner is clear and that the radiologists are aware of
the studies needed and the suspected injuries. It may include
ensuring that an operating room is being prepared and that the
anesthesiologist is aware of the status of the resuscitation. It
may include letting the interventional radiologist know that
the patient may be coming to the angiography suite directly
from CT.Besides being the architect of a dynamic plan, the
TTL must coordinate seamless transitions in resuscitation and
denitive care. As noted, this forward facilitation may save
hours of shock and its many downstream complications.
[27]. However, the essential considerations for transfer to
denitive care remain the same. Individual trauma teams
designated for each arriving patient must assess their patients
and develop specic strategies. The overall TTL, who must
remain above the fray of individual trauma resuscitations,
will pave the way forward for each team by activating all
potential downstream pathways simultaneously, then directing patients forward based on level of acuity and other considerations. A considerable part of the TTL’s time will be
spent activating pathways and providing forward communication, thereby ensuring that an institution-wide response
ows as seamlessly and efciently as possible. The same
principles of identifying the presence of shock and minimizing its duration and making the best decisions possible under
dynamic and uncertain considerations still apply, only on a
larger scale and with the added layer of decision-making
regarding prioritization and resource allocation in the presence of multiple patients.
The Role ofInformation Technology
The formulation of trauma resuscitation and transfer strategies represents the pinnacle of multimodal patient assessment, decision-making under conditions of uncertainty,
and team leadership. A wealth of experience has accumulated in each of these areas, and trauma centers around the
world have applied this experience, increasingly combining it with predictive tools and decision-making algorithms, to address shock from complex, multisystem
trauma with a prompt, aggressive, high-quality response
(Table32.2). New information technology tools, including
articial intelligence and machine learning algorithms,
may have the capacity to optimize the use of data in clinical decision-making, bring tailored trauma response algorithms to the bedside, and enhance communication at the
critical periods of transition between the emergency
department and denitive care [28, 29].
Special Considerations inMass-Casualty
Situations
Mass-casualty situations are discussed in detail elsewhere in
this text (Chap. 49). By denition, these events overwhelm
the usual processes of emergency trauma and surgical care
Table 32.2 Early resuscitation process measures from the American
College of Surgeons Trauma Quality Improvement Program
Trauma quality improvement process measures
Measurement of best Glasgow coma scale (GCS)
Time to operating room for hemorrhage control
Time to angiography for hemorrhage control
Transfusion in the rst 4hours (packed red blood cells (pRBCs) and
fresh frozen plasma (FFP))
274
Table 32.3 Features of high-reliability organizations
Sensitivity to operations
Reluctance to simplify
Preoccupation with failure
Deference to expertise
Commitment to resilience
Future Directions: Toward High Reliability Organizing
High reliability organizations (HROs), such as aircraft carriers and nuclear power plants, are those with complex operations that function under extraordinarily high-risk conditions,
where errors have potentially catastrophic consequences,
and yet almost never experience catastrophic failures [30].
They expect and are preoccupied by failure, but they strive to
contain and minimize the consequences of those failures.
Studies of HROs reveal some common features (Table32.3)
that together create mindfulness, collective intelligence, and,
ultimately, resilience. In healthcare, trauma teams exemplify
many dening features of HROs and have evolved with many
HRO features. At the core of this evolution has been the recognition that trauma care is complex with high stakes and
that successful teams require the engagement of all members
to minimize or avoid pitfalls. Similar considerations (shared
understanding of expected progress, early recognition of
worrisome trends, vigilance against cognitive biases, clear
communication in attened hierarchies, and strong organizational culture) dene the emerging concept of rescue. Failure
to rescue, dened as the ratio between mortality and total
number of complications, is increasingly seen as an important indicator of healthcare performance. As complex adaptive systems and HROs, trauma systems should embrace
complexity and risk, but have a strong ability to minimize
failure to rescue [31]. As the complexity of trauma resuscitation and the capability of trauma teams increase, trauma systems would benet from measuring and optimizing their
collective intelligence, reliability, and resilience.
N. Gawad et al.
Key Points
• Trauma team leadership, decision-making, and
organization are based on fundamental physiological principles including prompt reversal of shock
and minimization of secondary injuries.
• A picture of trauma patient disposition often develops early as primary survey data accumulate. Early
diagnostic imaging adjuncts to the primary survey
may also be directive. The trauma team should gear
itself toward one of six disposition strategies very
early on in order to avoid potentially life- threatening
situations and logistical delays: watchful waiting,
CT, interventional radiology, operating room, ICU/
trauma unit, or transfer to another facility for denitive care.
• Unstable patients are best managed in the operating
room.
• Forward planning and forward communication
should begin very early in the course of assessment
and resuscitation.
• Decision-making under conditions of uncertainty
can be guided by careful consideration of risks,
benets, and probabilities of the various possibilities based on emerging information. These decisions are often based on judgment and experience,
but may increasingly be informed by predictive
analytic tools.
• Trauma team leaders should maintain situation
awareness and pursue an open model of leadership
that encourages communication, engages team
members to maximize their potential, and establishes and pursues a clear and shared purpose.
These are key aspects of mindful, high reliability
organizations that recognize deviations from
expected trajectories and failures and that continuously adapt to mitigate risks.
Conclusions
Each trauma resuscitation is a coordinated, multidisciplinary
effort and a powerful application of healthcare resources in a
complex and time-dependent situation. Trauma resuscitation
serves “to organize and measure the best of our energies and
skills” in healthcare. Decision-making in trauma, incorporating anatomic and physiologic data, integrating technology,
and creating culture that is greater than the sum of its parts,
represents a rapidly evolving and exciting frontier in
healthcare.
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Emergency Critical Care Procedures
PaulB.McBeth andS.MoradHameed
33
Introduction
The purpose of this chapter is to provide a review of selected
emergency critical care procedures. A generalized approach
and description of indications, contraindications, controversies, and common pitfalls are provided. Topics covered
include: surgical airway management, vascular access, tube
thoracostomy, resuscitative thoracotomy, and diagnostic
peritoneal lavage. Detailed descriptions of individual procedures are referenced and detailed elsewhere.
Emergency Procedures andTeam Dynamics
The team architecture and dynamic is centered around a
trauma team leader (TTL) whose responsibility is to provide
oversight in the management of critically ill patients. The
TTL directs the ow of resuscitative efforts, including the
selection and prioritization of life saving procedures, based
on the patient’s presentation and information gathered by
other care providers—making closed-loop communication
practices essential. When possible, the TTL should avoid
engagement in specic procedures in order to facilitate a
cohesive ow of the resuscitation, but should remain aware
of the capabilities of team members and stay up to date on
procedural progress and success. Since emergency procedures conducted on critically ill or injured patients require
speed and efciency, the most skilled team member is usually selected to carry out these procedures in order to provide
the greatest chance of successful patient outcome. Specic
roles of each team member should be determined and
rehearsed beforehand. Regular simulation-based training is
P. B. McBeth (*)
Alberta Health Services | South Health Campus,
Calgary, AB, Canada
S. M. Hameed
Trauma Services VGH, Vancouver, BC, Canada
e-mail: morad.hameed@vch.ca
helpful to establish these roles as well as to determine group
dynamics, closed-loop communication with specic emphasis on procedure delegation and reporting, familiarization
with equipment, and awareness of institutional protocols.
Clear communication is essential when resuscitating a critically ill patient and performing emergency procedures. All
reasonable efforts should be made to ensure emergency procedures remain controlled and organized, incorporate sterile
techniques, and consider patient safety and comfort. The
health and safety of each team member are also paramount.
Personal protective equipment should be worn in all emergency procedures including gowns, gloves, eye wear, and
when appropriate lead aprons. In the era of the COVID-19
pandemic, N-95 respirators in addition to appropriate PPE
should be worn for any aerosol-generating medical procedures (AGMP). Post-procedure debriengs are helpful to
support learning and ensure quality assurance for improved
patient outcomes.
Airway Management
Emergency surgical airway management is an essential skill
required by providers of critically ill patients. A surgical airway is generally considered a procedure of last resort when
alternative attempts to capture a patient’s airway have failed.
The criteria prompting the need for surgical airway management is best summarized by the “can’t intubate, can’t ventilate” dictum where the care provider is unable to intubate or
provide effective bag mask ventilation. In particular, sustained hypoxemia during intubation efforts provides justication for initiation of surgical airway procedures. Other
indications for surgical airway management include: severe
facial or nasal injuries, massive facial trauma, possible cervical spine trauma preventing adequate ventilation, anaphylaxis, and chemical inhalation injuries. There are no absolute
contraindications to surgical airway management; however,
caution should be considered in patients with known underlying anatomical abnormality, tracheal transection, and acute
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_33
277
278
P. B. McBeth and S. M. Hameed
laryngeal disease due to infection or in small children under
the age of 10years [1, 2].
Emergency surgical airway management is often performed in critically ill patients, necessitating time-sensitive
management of the airway in an often austere environment
[3]. Given the urgent need for the procedure, availability of
resources is often limited. If time permits, the ideal location
for surgical airway management is in the operating room
(OR) where appropriate access to surgical instruments, anesthetic supplies, support teams, and lighting is available.
A cricothyrotomy is the procedure of choice in an emergent situation when unable to intubate. This is done by securing an airway passage through the cricothyroid membrane,
which in most patients is straightforward to identify on direct
palpation of the neck. This technique allows avoidance of the
vocal cords, thyroid isthmus, and associated vessels. There
are three main approaches to cricothyroidotomy: needle cricothyroidotomy, percutaneous cricothyroidotomy using the
Seldinger technique, and surgical cricothyroidotomy.
Descriptions of these procedures can be found elsewhere [4].
The decision of which approach to use is guided by both the
patient’s condition and the familiarity of the care provider
with the procedure. The needle cricothyroidotomy technique
is limited by the volume of gas exchange through the catheter and the need for a high-pressure gas source for jet ventilation; therefore, its effectiveness at ventilation is limited while
its capability to provide oxygen delivery is favorable. This
technique serves as a useful time bridge toward establishing
a denitive endotracheal intubation and is the preferred
method of securing a crash airway in infants and young children where surgical cricothyrotomy is contraindicated.
Percutaneous cricothyroidotomy using the Seldinger technique and surgical cricothyroidotomy are both equally effective at securing an airway. It should be noted that some
commercially available percutaneous cricothyroidotomy sets
do not have cuffed tubes, which may limit airway protection
and ventilation until conversion to a more denitive airway is
possible. In the authors’ experience, percutaneous cricothyroidotomy, which requires some force for tube placement
over the wire, without direct visualization of the airway, is a
less controlled procedure than open cricothyroidotomy. A
more simple surgical cricothyroidotomy can be successfully
completed using only a scalpel, bougie, and an endotracheal
tube. For both procedures, we recommend a vertical incision,
which can be extended based on palpation of anatomic landmarks and which may help avoid inadvertent injury to the
anterior jugular veins. Once a vertical incision is made, palpation for the cricothyroid membrane is completed. A scalpel is used to make an incision into the cricothyroid
membrane being mindful not to plunge the scalpel into the
posterior airway. Using the blunt end of the scalpel handle,
open the cricothyroid membrane and advance the bougie
along the side of the scalpel handle. The bougie should
advance easily if it is within the airway; then advance an
endotracheal tube over the bougie. The selection of percutaneous or open methods is dependent on the availability of
equipment and skill of the operator. Once the procedure is
complete, conrmation of location is essential prior to commencement of ventilation to avoid insufation of false passages. This can be done using a bronchoscope for direct
visualization, in-line capnography for conrmation of endtidal CO2, or small volume ventilation with an ambu-bag
with bilateral lung auscultation [2].
Once the surgical airway has been captured, the cricothyroidotomy should be evaluated by a surgeon to assess for
injury to the airway and neighboring anatomical structures.
This assessment is conducted in the OR followed by conversion to a tracheostomy. This helps to avoid the long-term
complications of glottis or subglottic stenosis, laryngeal stenosis, tracheomalacia, and dysphonia [4]. Early postprocedure complications include: bleeding, subcutaneous
emphysema, obstruction, esophageal or mediastinal perforation, aspiration, vocal cord injury, pneumothorax, and posterior tracheal wall perforation [4, 5].
Surgical airway management is a potentially life-saving
skill and should be part of the training repertoire of any surgeon, emergency medicine, or critical care physician. Given
the low incidence of surgical airway management, alternative training and credentialing modalities are needed, including phantom model, human cadaver, and animal simulation
[6].
Tube Thoracostomy
Tube thoracostomy is the insertion of a tube into the pleural
cavity to facilitate the drainage of air and uid. This procedure serves as both a diagnostic and therapeutic intervention.
In critically ill patients with undifferentiated shock, rapid
bilateral nger thoracostomy followed by chest tube insertion, even before chest X-ray evaluation, is a useful procedure for guiding diagnostic evaluation. Other indications for
tube thoracostomy include: pneumothorax, hemothorax,
hemopneumothorax, hydrothorax, chylothorax, empyema,
pleural effusion, and prophylactic decompression for patients
undergoing air transport [7–9]. There are no absolute contraindications, but relative contraindications include: coagulopathy, pulmonary bullae, loculated pleural effusion,
empyema, or pulmonary, pleural, or thoracic adhesions. The
size of the tube placement dictates the surgical technique
used. Small pigtail drains are placed using CT or ultrasound
guidance using the Seldinger technique [10]. Larger surgical
drains are placed under direct visualization with a surgical
approach involving tissue dissection. Detailed descriptions
of procedural steps for tube thoracostomies are provided
elsewhere [11].
33 Emergency Critical Care Procedures
279
Controversies
Despite numerous studies, the use of prophylactic antibiotics, appropriate tube size selection, and management of
occult pneumothorax remain controversial topics.
Antibiotics
The need for prophylactic antibiotics prior to thoracostomy
tube placement is controversial and is dependent on the clinical situation. Several studies have been conducted to evaluate the need for prophylactic antibiotic use prior to chest tube
placement. The majority of these studies have been limited
by heterogenous population mix and lack power to demonstrate a clinically signicant difference. The Eastern
Association for the Surgery of Trauma guidelines does not
support the use of prophylactic antibiotics [12]. Patients with
non-traumatic spontaneous pneumothorax do not require
prophylactic antibiotics prior to chest tube insertion. A recent
systematic review and meta-analysis of patients with penetrating thoracic trauma demonstrated signicant reductions
in the risk of empyema (OR 0.28, 0.14–0.57) [13]. This is
supported by a meta-analysis by Sanabria, which demonstrated that the use of prophylactic antibiotics in patients
with chest trauma decreased the incidence of post-traumatic
empyema (RR 0.19, 0.07–0.50) and pneumonia (RR 0.44,
0.27–0.73) [14]. Despite these studies, the question of prophylactic antibiotics remains controversial. Infectious complications of tube thoracostomies can be minimized by
ensuring adequate drainage of hemopneumothorax, using
appropriate sterile techniques for tube placement, and appropriate securing of the chest tube to ensure unintentional
dislodgement.
Tube Selection
Adequate drainage of traumatic hemothoracies is essential in
order to prevent retained hemothoraces, complications of
additional tube thoracostomy, infection, and trapped lung.
The optimal tube size for drainage of pneumo- or hemothoraces is unknown. A recent study by Inaba demonstrated no
clinically signicant difference between 28–32 and 36–40
French chest tube size [15]. A smaller study by Kulvatunyou
demonstrated 14 Fr pigtail catheters could be effectively
used to drain hemothoracies in stable trauma patients [16].
However, pigtail catheters should be reserved for stable
patients only and avoided in urgent/emergent situations
where time is of the essence. In addition, these require adequate training and experience in both image guidance and
appropriate patient selection. Patients at risk of a large air
leak due to a bronchial-pleural stulae should have a larger
bore tube (20-28Fr).
Occult Pneumothorax
Occult pneumothorax is dened as a pneumothorax detected
with thoracic or abdominal CT, and not diagnosed on preceding supine anteroposterior chest X-ray. Patients with small
occult pneumothoraces in the absence of positive pressure
ventilation can be managed safely without tube thoracostomy. The optimal treatment of patients with occult pneumothoraces requiring positive pressure ventilation is unknown.
Recent retrospective data suggest tube thoracostomy may
not be required. However, data from two small randomized
control trials suggest otherwise [17–20]. The authors of this
document support close monitoring of occult pneumothoraces in the setting of positive pressure ventilated patients.
Complications andPost-tube Thoracostomy
Management
Close observation of patients following chest tube placement
is needed to ensure resolution of the initiating reason for tube
placement and for monitoring of immediate or delayed complications. Complications of tube thoracostomy include:
unresolved or re-accumulation of pneumothorax or hemothorax, improper placement (pleural positioning, lung ssure
or parenchyma, intra-abdominal), bleeding, organ penetration, tube dislodgement, and empyema. Many of these complications can be avoided by appropriate training and
rigorous attention to surgical techniques, including consideration of using prophylactic antibiotics, careful chest X-ray
review and landmarking, sterile technique, and a mindful
nger sweep of the pleural space before tube introduction.
Hemothoraces should be monitored with daily chest X-rays
to ensure appropriate resolution of the chest drainage.
Retained blood in the chest after chest tube placement
increases the risk of empyema and brothorax by as much as
20%, prompting additional drain placement or surgical
decortication [21]. Retrospective and randomized control
trial data support the use of early (less than 5 days post
injury) video-assisted thoracoscopic surgery (VATS) for
evacuation of retained hemothoraces [21–23].
Timing of chest tube removal is dependent on the resolution of the original clinical presentation. Chest tube drainage
less than 100cc/day with complete radiographic improvement of hemo/pneumothorax may prompt tube removal in
the absence of positive pressure ventilation. Caution should
be used in patients under positive pressure ventilation as
chest tube removal may increase the risk of recurrent pneumothorax, leading to possible tension pneumothorax.
280
QP r
()
∆µ
48/L
P. B. McBeth and S. M. Hameed
Vascular Access
Early establishment of vascular access in patients who are
critically ill is essential for both volume expansion and medication delivery. Selection of vascular access sites is dependent on the goals of resuscitation. Large volume resuscitation
is best achieved using large bore peripheral access. Central
access is usually reserved for medication delivery; however,
large volume resuscitation can also be achieved.
Large volume resuscitation is restricted by the size of the
intravenous access. The ow is determined by the HagenPoiseuille equation, which states:
=×
where:
Q=Flow in Liters/second.
μ=Viscosity in Pa.s,
P=Pressure in Pascals.
r=Radius of the tube in meters,
L=Length of the tube in question in meters.
Essentially, large bore size and short length are needed to
maximize ow. Tables 33.1 and 33.2 outline typical ows
seen with catheters.
π
Peripheral Intravenous Access
Peripheral intravenous access is the mainstay of early uid resuscitation of critically ill patients. Indications for peripheral intravenous access include: venous blood sampling, intravenous uid
and medication infusion, blood transfusion, and intravenous contrast administration. Access points include both upper and lower
limbs, including the long saphenous, cephalic, basilic, and
median cubital veins. Contraindications to intravenous access
include: extremity with signicant edema, burns, sclerosis, phlebitis, or thrombosis, and ipsilateral radical mastectomy. Early
complications include bruising inltration, interstitial uid/medication delivery, and air embolism. Late complications include
thrombophlebitis, infection, nerve damage, and thrombosis [24].
Central Intravenous Access
Central venous catheterization is used to access central veins
for medication and uid delivery and patient monitoring of
central venous pressures and right heart catheterization. A
variety of sites can be used, including femoral, subclavian,
and internal/external jugular veins. Each site has its own set
of advantages, disadvantages, and risk of complications outlined in Table33.3.
Table 33.1 Flow characteristics in peripheral vascular catheters
Gauge size Inside diameter (mm) Length (mm) Flow rate (mL/min)
16 (gray) 1.3 30 220
18 (green) 1.0 30
50
20 (pink) 0.8 30 60
Abbreviations: mm millimeters, mL/min milliliters per minute
Table 33.2 Selected characteristics of triple-lumen central venous catheters and intraosseous access
Size (Fr) Length (cm) Lumens Lumen size (Ga) Flow rate (mL/min)
7 16 Distal
Medial
Proximal
7 20 Distal
Medial
Proximal
7 30 Distal
Medial
Proximal
8.5 (Cordis) 10 Single 8.5 Fr 333
Intraosseous [24] 5 Single 15 165
Abbreviations: Fr French, Ga Gauge, cm centimeters, mL/min milliliters per minute
16
18
18
16
18
18
16
18
18
105
60
57
30
32
52
25
27
38
17
18
33 Emergency Critical Care Procedures
Table 33.3 Central line placement
Site Advantages Disadvantages Complications
Internal jugular Anatomic landmarks are easy to
identify with ultrasound
Head-of-table access
Can recognize and control bleeding
with direct pressure
Minimal risk of pneumothorax
Malposition of catheter placement is
rare
Subclavian Good external landmarks
Improved patient comfort
Easier to maintain dressings
Accessible during airway management
or patients with C-spine collars
Femoral Good external landmarks allowing for
rapid access
Technically easy
Does not interfere with CPR
Useful alternative with coagulopathy
Trendelenburg position not required
Abbreviations: CPR cardiopulmonary resuscitation, CVP central venous pressure, PA pulmonary artery
Difcult to access during emergency
airway management
Risk of carotid artery puncture
Patient discomfort
Vein prone to collapse with
hypovolemia
Avoid if concern about cerebral
perfusion
Avoid in cervical trauma patients
Unable to compress bleeding vessels
Blind procedure
Experience related success rate
Longer path from skin to vessel
Catheter malposition
Limits patient mobilization
Delayed circulation of drugs during
CPR
Difcult to keep site sterile
Increased risk of iliofemoral thrombosis
Not reliable for CVP of central venous
gas measurements
Pneumothorax
Hemothorax
Chylothorax
Neck hematoma and tracheal
obstruction
Endotracheal cuff perforation
Tracheal perforation
Brachial plexus injury
Air embolism
Cardiac dysrhythmia
Thrombosis
Pneumothorax
Hemothorax
Brachial plexus injury
Hematoma
Air embolism
Cardiac dysrhythmia
Thrombosis
Arterial puncture
Bowel injury
Retroperitoneal hematoma
Psoas abscess
Bladder injury
Air embolism
281
Indications for central venous access include: emergency
venous access; high-volume/ow resuscitation; central
venous pressure monitoring; inability to obtain peripheral
venous access; repetitive blood sampling; administration of
hyperalimentation, caustic agents, or concentrated uids;
hemodialysis or plasmapheresis; and placement of transvenous cardiac pacemakers or pulmonary artery catheters.
Contraindications for central venous access include: infection
over the placement site; distortion of landmarks by trauma or
congenital anomalies; coagulopathies, including anticoagulation and thrombolytic therapy; pathologic conditions, including superior vena cava syndrome; current venous thrombosis
in the target vessel; prior vessel injury or procedures; morbid
obesity; and uncooperative patients. Complications for central venous access are outlined in Table33.3. Infection rates
for internal jugular, subclavian, and femoral central lines are
reported as 8.6, 4.0, and 15.3 per 1000 catheter-days, respectively [24]. Thrombosis rates of internal jugular, subclavian,
and femoral central lines are reported as 1.2–3, 0–13, and
8–34 per 1000 catheter-days, respectively [24].
Intraosseous Access
Intraosseous (IO) access is a technique where a needle is
advanced into the bone marrow to achieve an entry point into
the systemic venous system. IO route provides a rapid and
effective means of administering drugs, uid, and blood.
Blood can also be drawn from an IO device and used for
blood gases, electrolyte and hematologic evaluation, and
blood cultures [25–27]. This technique is indicated for adult
patients in whom attempts at peripheral or central venous
access have been unsuccessful. This may include adult
patients with burns, trauma, shock, dehydration, or status
epilepticus [28]. Multiple sites, including the iliac crest,
femur, proximal and distal ends of the tibia, radius, clavicle,
and calcaneus may be used [29–32]. A wide variety of commercial IO devices are currently available. It is important
that the provider is familiar with local hospital practice and
equipment. Detailed description of IO placement is provided
elsewhere [33]. IO devices should be avoided in patients
with orthopedic or vascular trauma because of the risk of
extravasation. Other contraindications include cellulitis or
burns over the insertion site, patients with known underlying
bone disease such as osteogenesis imperfect, and previous
IO attempts on the ipsilateral side. Technical difculties are
the most common complications and are associated with
equipment unfamiliarity. Complications of IO devices
include malposition resulting in skin and bone trauma, compartment syndrome from unrecognized extravasation, epiphyseal injuries, and fat embolism. Prior to using an IO site,
10cc of normal saline should be ushed through the line.
Infusion of uids through the needle at high rates is sometimes associated with patient discomfort. IO access is meant
only for temporary access and should be removed when
denitive intravenous access is established.