Central and arterial line insertion in the emergency department

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Target exams

Red flags

• Ultrasound guidance is the standard of care for central venous catheterisation — never cannulate the internal jugular blind when ultrasound and the skill to use it are available
• Post-procedure chest X-ray is mandatory after every internal jugular or subclavian line — an apical pneumothorax may be occult on the immediate film and become a tension pneumothorax once positive-pressure ventilation begins
• A venous air embolism is a can't-miss emergency during catheter advancement — keep the needle occluded at every stage, place the patient head-down, and at the first sign (cough, desaturation, mill-wheel murmur) go head-down left lateral, 100 per cent oxygen, and aspirate through the line
• If the carotid artery is cannulated with the large-bore dilator, do NOT remove it — leave the catheter in place and call vascular or interventional radiology; removing it in the ED risks exsanguination or stroke from embolised thrombus
• Avoid the subclavian route in the coagulopathic patient and in the patient who cannot tolerate a pneumothorax — the subclavian vessels are not compressible, and the pneumothorax risk is the highest of any site