Inspired by the recent ACRRM RMA 2013 Conference JAMIT video competition (Just A Minute Instant Tutorial), we made a little video about one of our favourite trauma procedures. Trauma patients frequently arrive in shock, peripherally shut-down, with collapsed veins. Traditional dogma states all trauma patients should have “2 large bore, 14G or 16G IV’s inserted”. Well 14G and 16G IV’s are frequently hard to get in to cold, constricted, collapsed, empty veins, and all too often I see people prang numerous attempts at large bore IV insertion, not obtaining access and ruining the veins for further IV access attempts.
In under a minute, you can insert a 20G IV (pink) into a cubital fossa, forearm, or saphenous vein, and use the Seldinger technique to feed a guidewire through it, and then insert a short, 7 or 8.5Fr (note French, not Gauge) rapid infuser catheter (RIC) into the vein. You can also use any IV that the patient arrives with to railroad the wire and upsize to a RIC using the Seldinger technique. This is a rapid, effective technique that obtains access that is superior to a standard IV.
Actual flow rates through these catheters is hard to measure, and vary depending on the connectors, infusion pressure and delivery device (here’s a nice comparison between a Level-1 system and a Haemonetics Rapid Infusion System), but RIC catheters clearly have a higher flow rate than standard IV’s.
So here you go, a JAMIT video entitled “How to save a life with a 20G IV”.
If you have trouble getting a RIC line in, here’s some tips:
- Awake patient? Use local anaesthetic!
- You need at least 5-7cm of straight vein. Hence the insertion sites listed above
- Deeper sites like femoral or subclavian are NO GOOD for RICs – the catheter is too short. (Try a longer cordis) You could use the external jugular – but not often available in collared trauma patients.
- If the wire won’t feed smoothly into the vein, it’s either hitting a valve or a sharp bend in the vein – you can try pulling it in & out gently to see if you can get it past the obstruction (the tips on the wire are very soft, you won’t pop the vein), but if you can’t – don’t insert the RIC, it will hit the same obstruction & you may pop the vein.
- You need to make a small incision (3-4mm) with the small green scalpel – if you don’t the RIC or dilator will hang up on the skin and not go in. If your incision is even 0.5mm away from the wire, there will be a small tissue bridge that will catch the RIC & stop it going in
- When you make the incision – blood will well up at the site and obscure your view/make a mess – have some sterile gauze folded up & ready to put some pressure/soak up the blood as soon as you make the cut.
One thought on “How to save a life with a 20G IV – JAMIT Video”
Nice video – see also my JAMIT on the same http://vimeo.com/73497266
…or the rather more languid (but better sound track) over at https://vimeo.com/59608480 from ’50 shades of brown’ at http://www.KIDocs.org
(dontcha love a bit of AccaDacca and Barry White?)
– there’s also a copy of the latter movie in the video files section of Roberts & Hedges ‘clinical procedures in EM’
Don’t forget you can’t get the seldinger wire through anything smaller than a 20G (so a 22G or heaven forbid a 24G ain’t gonna cut it)
…and warm your fluids, being careful not to overfill the patient and dislodge any clot /dilute clotting factor if they’re bleeding