Case summary:

An ALS crew responded to a nursing home for an elderly man with the chief complaint of “fever and BP dropping.”  They found him lying in bed, with pale clammy skin, alert but oriented only to self, and a weak peripheral pulse.  His airway was patent but he was tachypneic.  Nursing staff reported that he was there receiving IV antibiotics for a leg infection via a peripherally inserted central catheter (PICC).  The nurses also report that at baseline, the patient is alert and fully oriented.  The crew quickly identified that he was critically ill so they obtained vitals and began resuscitation. 

Vitals: BP 86/45,  HR 120,  RR 28,  Sat 90%,  glucose 552, ETCO2 22

The crew placed the patient on O2 and attempted an IV, but were unable to get access.  The crew was worried the patient had septic shock and needed access ASAP.  They considered IO, but given the patient already had a PICC, the called med control to get permission to administer fluids and push dose epi via the PICC to stabilize the patient.  Med control gave the go ahead and the crew gave both fluids and push dose epi via the PICC.  Vitals just prior to arrival in the ED were:

Vitals: BP 114/63,  HR 119,  RR 21,  Sat 94%,  ETCO2 25

Highlights of the case:

What types of central lines to patients have outside of the hospital?

There are three types of central lines that patients will routinely have outside of the hospital: PICCs, tunneled hemodialysis (HD) catheters, and subcutaneous chest ports.  PICCs are catheters that start in the arm with the tip of the catheter in the superior vena cava.  These are used to give IV medications for a prolonged period since the stay patent longer than normal IVs and are less prone to infection than normal central lines.  Tunneled HD catheters are used to allow patients to undergo dialysis outside the hospital prior to their AV fistula or AV graft being placed or being usable.  Chest ports are used when patients require frequent but intermittent IV access since they are the least prone to infection if accessed properly. 

When can EMS use central lines?

IV access is vitally important in the treatment of critically ill medical patients.  This patient had evidence of having septic shock, so stabilizing the BP with both fluids and push dose epi is needed to prevent cardiovascular collapse.  Often it is difficult to obtain access in our most critical patients since they are so dry that we cannot easily feel vessels, or they have been stuck so many times that only tough to access veins remain.  While IO is certainly an option, some patients already have central access available.  While use of these lines is not permitted by our local protocol, it is within the scope of practice in the state of Ohio for paramedics.  With an online med control order, EMS providers can do anything they have been trained to do that is within their scope of practice, even if it is not in their protocol.  Indications for use are critically ill patients and an inability to obtain a better alternative.  Both PICCs and tunneled HD catheters can be considered in patients in either extremis or in cardiac arrest, but care should be taken to use sterile technique to prevent infection so that if the patient survives, the line does not need to be removed to due infection from our use.  In this case, the crew felt that using the PICC was superior to an IO since the medications are being delivered directly to the heart and IOs are very painful (given that the patent was awake).  This was great thinking and it allowed them to quickly and effectively resuscitate the patient.