“Arterial Lines in Cardiac Arrest” By Dr. Weingart From CriticalCareNow

Posted on October 28, 2023 by Tom Wade MD

Today, I reviewed and embed “Arterial Lines in Cardiac Arrest” By Dr. Scott Weingart from CriticalCareNow. Note to myself: This resource is outstanding and is worth reviewing often.

This video has two parts.

  • Placing The Femoral Arterial Line In Cardiac Arrest 0:00 – 8:58
  • Interpreting The Arterial Line Waveform During Cardiac Arrest 9:00- 11:19

Both parts are outstanding.

2,039 views Apr 9, 2023 ResusX:Podcast

Welcome to the ResusX:Podcast. This is a FOAMed podcast dedicated to the sickest patients you are for. In this episode, Dr. Scott Weingart discusses the role of arterial lines in the management of cardiac arrest patients. He explains the importance of continuous blood pressure monitoring and how arterial lines can provide more accurate and reliable blood pressure readings than non-invasive methods. Scott also discusses the practical aspects of placing arterial lines in cardiac arrest patients, including the potential benefits and risks. He emphasizes the need for proper training and experience in arterial line placement and management. This episode is a must-listen for anyone involved in the care of cardiac arrest patients. The insights and practical tips shared by Dr. Weingart are sure to be valuable for clinicians at all levels of experience. Want to learn more about our educational resources and our upcoming conferences? Check out www.ResusX.com

All that follows is from the transcript of the above resource.

Placing The Femoral Arterial Line In Cardiac Arrest

0:00 – 8:58

[These are outstanding instructions on performing the procedure.]

I’ve gotten a lot of questions on the show about how to actually place an arterial line during cardiac arrest. So I figured I’d give this lecture to help you learn this vital skill.

Now, I’m not going to teach you just how to do it in terms of being able to monitor, but coming down the pike are a whole   bunch of endovascular therapies like REBOA that I think will be part of medical arrest within the next five years. So I’m going to teach you also how to access the femoral artery to be able to do
procedures like that as well.

All right let’s talk about stuff. I do not like the needle that comes with the standard  arterial kit. They’re tiny. They’re 20 gauge so they don’t show up well on ultrasound.  They don’t reach obese patients. They’re fine if you have the time and you can just switch out if they’re too short but during your cardiac arrest you want one shot getting it.  And that means using a better needle. Now you could just grab a needle from a central line kit or from a Cordis kit and those will work.

Those  will be 18 gauge they’re much longer than the standard art  line needles. That’ll get the job done. But since I don’t want to waste an entire kit just to steal a needle I actually have a purpose-built needle [that I use]. I don’t take money from any of these folks but a company called Pajunk makes the best one in my estimation.

Tt is insanely crenellated soit’s echolucent. You can see it like a

Catherine [a previous speaker] said you could just use a standard u ICU art line but the problem with that is they don’t take the wires that you may use for any additional procedures like ECMO, like REBOA, or like your IR people being able to use it.

So really when you want to place during Cardiac Arrest is something that’s at least four French. It’s 18 gauge and that’ll allow you to do anything you want with this later on.

And so what we have is we have four French sheaths. They

Could you use a central line if as long as they were narrow. Sure. They make five, a five French central line.  Sure but ideally this [the four french sheath he mentions above is (I think what he is talking about)  is just big enough and it’s as small as you get away with and it’s really what I like. So four French sheath*, all right.

*French gauge from Radiopaedia.

Last revised by Derek Smith◉ on 26 Jun 2021

The French gauge (Fr) (also known as the French scale or system) is used to size catheters, and other instruments, in interventional radiology and surgery. In some parts of the world, the Charrière (Ch) is used as the name of the unit, in honor of its inventor.

French sizing
The French system is simple, one increment on the French scale is equal to 1/3 millimeter, e.g. 8 Fr catheter is 8 x 0.33 mm = 2.67 mm in caliber.

Unlike the needle gauge system, the French system has no set lower or upper limit, and users generally find it a lot less confusing, as the French size is proportional to the diameter.

Some common French sizes with equivalent metric diameter and circumferences:​

3 Fr is 1 mm (diameter) and 3.14 mm (circumference)
4 Fr is 1.33 mm and 4.19 mm
5 Fr is 1.67 mm and 5.24 mm
6 Fr is 2 mm and 6.28 mm
7 Fr is 2.33 mm and​ 7.33 mm
8 Fr is 2.67 mm and​ 8.34 mm

Resuming Dr. Weingart’s lecture:

Let’s talk about prep.  I prep my needle simply by taking it out of its holder because I don’t use a syringe on my needle for art lines at all in a cardiac arrest or otherwise so it makes it super easy. You want to get your wire prepped.

Vessel Location 3:39

All right let’s talk about vessel location.

Now you need to be able to find artery not using any of the standard stuff.

You can’t hit a vessel and see “oh it’s pulsatiting. Pulsatility disappears during Cardiac Arrest [because]  they’re both pulsatile.

You can’t go by color [because] they [both] ook the same color during Cardiac Arrest.

The only thing you could use is their anatomy on ultrasound; the thick wall [femoral artery] versus  the thin wall [femoral vein].

Then you find them both [using ultrasound].and then you compare [them] and say [that is the one that is the femoral artery].

That [ultrasound] is the only thing that legitimately will work during cardiac arrest.

So do not use these other techniques to find both vessels and that [ultrasound imaging] will allow you to compare [the walls] and say this one’s thick and this one’s thin.

And the vein gets really big during cardiac arrest and the artery [gets] really small so you really have to go looking for that artery wall.

Then you want to find the right spot on the artery, which means you want to be not in The Superficial Artery where a lot of ED arterial lines are placed.

But [rather] you want to be in the common femoral artery.

But you don’t want to be so high in the common femoral artery that you risk retroperitoneal puncture [if you back wall it because you won’t be able to compress the puncture site].

So what you really want is do is–you want to be in the common femoral vessel which is distal to the inguinal ligament.

That’s  [the common femoral artery] you move down the leg distally until it splits into two.

You then move back up until it just turns int0 one (that’s right at the bifurcation) and then you move two centimeters up from that [point]. That’s going to put you in that  sweet spot between the inguinal ligament and the bifurcation and that’s exactly where you want your needle tip to enter the vessel.

That’s not where your needle enters the skin because you need some time to progress underneath the skin to get right under your probe face so that is where you want to hit the vessel wall.

Right, let’s talk about hitting the artery.

CPR 5:23

All right, CPR is ongoing. That’s going to make this tougher. [But] it doesn’t make it impossible.

It makes it tougher [but] what makes it a lot easier is if you have mechanical CPR like a Lucas device [because there is] much less movement at the groin than with hand CPR.

So how do you then duplicate that nice placid effects [meaning little or no movement at the pelvis when you have people doing hand CPR?

You have a buddy hold the pelvis and really stabilize it and that takes away the movement the pelvis from that hand CPR.

But mechanical [CPR] makes everything so much easier.

all right now you have a lot of bad

techniques that you get in the habit of

in emergency medicine uh you you shake

shag right like so you you’re you’re

looking for your needle tip and it’s not

right in the plane you want so you turn

to the left and then you oh it’s more to

the right and and you find this very

inundating path uh to from the skin to

the vessel now you get away with it with

tiny little things but when you get used

to placing larger things like repos or

uh ecmocatheters uh you really need a

straight shot which means if you need to

adjust your annual you come all the way

out to the skin you readjust your angle

and then you could go in so one

continuous Motion One continuous angle

and that angle shouldn’t be steep which

is what happens with the standard

arterial line needles it’s like a

magnetic ingredients to hit that vessel

that will not work to allow big

catheters to flow in from the skin all

the way to the vessel so what you want

to do is a 45 degree angle which means

you need a longer needle and then you

want to hit that right spot on that

vessel which means the anterior wall not

side uh entry into that artery

I’ve hold my needle like a dart

and that gives me the most control and

I’ll stabilize on the patient’s leg

while and entering with that dart-like

motion all right now there’s two ways to

get the needle from the skin into the

vessel there’s the way the occurred

generation is most commonly trained in

which is this needle walking where you

know you have your probe you put the

probe right on over the needle you move

the probe a little the needle disappears

you move the needle you find it again

you move the probe it disappears and

that’s fine but it takes a while and it

prevents you from keeping the Probe on

the exact spot you want to hit on that

common Federal artery which is we’ve

already mentioned is super important so

that doesn’t work now what does work but

it’s very difficult is called vessel

trigonometry where you will actually put

your probe on where you want to hit the

vessel you’ll see how deep it is you’ll

actually enter with the needle at the

skin that far back from the probe phase

so if it’s two centimeters to handle put

your needle two centimeters back from

the probe phase and at a 45 degree angle

thanks to the laws of trigonometry at

the point where it is right above the

vessel is right under your probe face

and so that’s the first time you’ll see

the needle tip and then you can watch it

in real time puncture The Vessel like I

say it’s a pro level move and most of

the time we know teacher trainees this

so how do we safely do both keep the

probe over exactly where we want to hit

and

um allows to see the needle tip we do

the fan right so instead of removing the

probe we just change the angle of the

probe so we can see the needle and then

we fan in either fan needle fan needle

and then you get the best of both worlds

so that’s what I recommend learning all

right attaching the wire you could do it

with your non-dominant hand but I really

like to re-grip the needle tip with my

uh my left hand on my right hand

dominant player I could do ambidextrous

but I’m better with my right and I

regret so I got in I regrip and then I

pick up the wire that’s right next to me

and place it into the Hub and since it’s

you know the wire is exposed I could do

that in one motion that’s how I like the

path the wire during this because it

gives the least amount of time to lose

your position in the vessel

Interpreting The Arterial Line Waveform During Cardiac Arrest

9:00- 11:19

All right now one last wrinkle and I I
don’t know if you would have heard about
this before. It was a revelation to me
when my buddy Pio Burberry uh actually
got in touch with me and said you’re
doing this [waveform interpterpretation] all wrong because up until that point I would get these incredibly
low diastolic blood pressures on my art
line [waveform] and what you would actually  say
is  oh my God I need to tell more heavy
they’re not getting any systemic
vascular resistance and what it turns
out is the machines are giving you the
wrong numbers you cannot use the numbers
on your arterial line ah tracing on the
monitor. Like if it says 120 over minus 10 the diastolic is not minus 10. The systolic isfine but the diastolic is a lie and you cannot use those numbers you actually have to look at the waveform itself because what happens is the upstrokeof compressions whether it be mechanical or by hand is generating some negative pressure in there and that gives you a temporary low point you can see on point a The Black Arrow on this slidthat’s what the machine is going off but that is not that’s just a perturbation in the chest that is not representativeof the actual diastolic blood pressures it’s an anomaly and it’s because the

 

 

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