Most of us were taught to place central lines using the wire through needle Seldinger technique, but using the introduction catheter instead of the needle makes successful wire insertion more likely and facilitates venous confirmation. A 7 minute screencast.

on vimeo

operating room video of wire through catheter technique. recommend viewing at 2x speed.

Update 1 Lee 2015 compares wire through needle and wire through catheter and shows that wire through needle is (slightly) better. The operators were anesthesiologists very experienced in central line insertion, which may account for their results. In the less controlled ED environment, with providers who don’t place a lot of lines (especially learners), the tendency of the needle to move before the wire can be transmitted may be more important. Also they did not confirm venous location in this study, which should be done whenever feasible and is greatly facilitated by the wire through catheter technique. Still, I’m aware of no data comparing the two techniques other than this (which appeared a few weeks after I posted the video), so though my success rate is definitely higher since I switched to wire through catheter, your mileage may vary.

Update 2  There are two advantages of the wire through needle (conventional approach): the needle is functionally slightly longer than the catheter, and the needle doesn’t kink. Neither of these advantages make a difference at the IJ site, and where I work almost all lines are IJ, so I didn’t mention this in the video. Based on feedback, I am surprised (and pleased) at how many non-IJ lines are being placed out there. If there is a lot of flesh in between the skin and the vein, for example at the femoral site in an obese person, the catheter can kink. This can be managed by keeping the pannus out of the way and keeping the skin taut throughout the procedure (flabby groin tissue can interfere with wire advancement as well, regardless of which technique you use to transmit the wire), but this requires an extra set of hands. At the subclavian site, the problem is not flesh but distance–sometimes you enter the vein relatively far away from where you enter the skin, and in this case the couple of millimeter difference between the wire and the catheter can be relevant. You can overcome this problem, in cases where you have to hub the catheter to get into the vein, by applying gentle continuous forward pressure on the hub until the wire is in the vein.

 

Audio

Slides

References

Cardiologists use calipers. Intensivists write little marks on a page and march them across. Emergency providers fold the ECG in half and hold it up to the light. Or the sun.

 

Fold the tracing in half. Hold up to the light.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Now align the QRS complexes. The rhythm is regular.

2 regular rhythm overlap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Here is another example.

3 irregular rhythm prelim fold

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Irregular. Cannot line up QRS complexes.

4 irregular rhythm overlap

 

 

 

headache ddx.001

 

emergency clinicians do not rule in migraine or other benign causes of headache. unless the headache is congruent to an established pattern for that patient, the history and physical specifically targets these 13 conditions.

subarachnoid hemorrhage: family history, PCKD, known berry aneurysm, sudden and maximal intensity at onset, posterior location

intracerebral hemorrhage: trauma, coagulopathy, decreased level of consciousness, hypertension

CNS infection: fever, immunocompromise, CNS instrumentation, recent head/face infection, meningismus

increased intracranial pressure: slowly progressive, cancer history, worse in morning, worse with head in dependent position, papilledema

carbon monoxide toxicity: contacts with similar illness, locationality (worse at home or at work)

acute angle closure glaucoma: unilateral anterior location, precipitated by darkness, change in vision, red eye

temporal (giant cell) arteritis: elderly, temporal location, jaw claudication, shoulder girdle symptoms

cervical artery dissection: unilateral pain involving neck/face, trauma history

cerebral venous sinus thrombosis: thrombophilia, neurologic signs/symptoms in non-arterial distribution, eyelid edema, proptosis

hypertensive encephalopathy: altered mentation, marked hypertension, improves with antihypertensive therapy

ENT/dental infection: ear, sinus, dental findings

idiopathic intracranial hypertension: young overweight female, hormone use, vision changes

preeclampsia: late pregnancy or postpartum

EDSOSC Screenshot

 

In acrobat format.

Thanks to pandrus for his assistance.