Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Central Venous Access - The Hypotensive Patient

Patient Demographics

• Age: 62 years
• Sex: Female
• Occupation: Retired teacher

Chief Complaint

"She's been vomiting blood all day."

History of Present Illness

A 62-year-old female presents with hematemesis. She reports multiple episodes of vomiting "coffee ground" material since this morning, followed by bright red blood in the last hour. She feels weak and lightheaded. She has a history of alcohol use disorder and was told she has liver problems. She appears acutely ill and has poor peripheral venous access.

Initial Assessment

ESI Level: 1 - GI hemorrhage with hemodynamic instability

First Impression:

• Appearance: Ill-appearing, pale, lethargic
• Work of breathing: Tachypneic
• Circulation: Pale, delayed cap refill

Vital Signs:

• Heart rate: 128 bpm
• Blood pressure: 78/48 mmHg
• Respiratory rate: 24 breaths/min
• SpO2: 94% on room air
• Temperature: 36.2C
• GCS: 14 (E3V5M6)

Immediate Need for Vascular Access

Peripheral IV Attempts:

• Two failed peripheral IV attempts (poor veins, edema)
• Patient unstable, needs immediate access

Options:

1. Intraosseous (IO): Fast, effective for resuscitation
2. Central Venous Catheter (CVC): Multiple lumens, can give large volumes
3. Ultrasound-guided peripheral: May be successful

Decision: Need CVC for resuscitation AND vasopressors likely needed → Place central line

Central Line Site Selection

This Patient:

• Coagulopathic (liver disease) → Avoid subclavian
• Possible airway intervention needed → Avoid IJ initially
• Femoral CVC selected - Appropriate for emergent access in coagulopathy

While Preparing for CVC

Intraosseous Access Placed:

• Proximal tibia
• Resuscitation started via IO
• Buys time for CVC placement

Central Venous Catheter Insertion - Femoral

Equipment:

• CVC kit (triple lumen catheter)
• Ultrasound with linear probe (vascular access)
• Sterile gown, gloves, mask, cap
• Full sterile drape
• Sterile saline for flushing
• Lidocaine 1%

Ultrasound-Guided Femoral Vein Access:

Landmarks:

• Below inguinal ligament
• Medial to femoral artery (use ultrasound to confirm)
• NAVL: Nerve-Artery-Vein-Lymphatics (lateral to medial)

Procedure (Seldinger Technique):

1. Position: Patient supine, leg slightly abducted and externally rotated
2. Sterile prep and drape: Maximum barrier precautions
3. Ultrasound: Identify femoral vein (compressible, medial to artery)
4. Anesthesia: Lidocaine to skin and subcutaneous tissue
5. Access: 18g needle with syringe, ultrasound-guided, advance into vein
6. Confirm venous blood: Dark, non-pulsatile flow
7. Guidewire: Pass J-wire through needle, maintain ultrasound visualization
8. Nick skin: Small incision at wire entry site
9. Dilator: Pass dilator over wire, remove
10. Catheter: Pass triple-lumen catheter over wire, remove wire
11. Confirm placement: Aspirate and flush all ports
12. Secure: Suture in place, sterile dressing

Confirmation

Methods:

• Blood aspirated from all 3 lumens
• Transduced waveform confirms venous (not arterial) access
• Chest X-ray not required for femoral line (no pneumothorax risk)

Resuscitation Via Central Line

Administered:

• 2L crystalloid (pressure bag)
• 4 units PRBC
• 2 units FFP
• Norepinephrine initiated (patient required vasopressors)

Response:

• BP improved: 92/58 mmHg on norepinephrine 0.1 mcg/kg/min
• HR: 108 bpm

Secondary Survey

SAMPLE History:

• Symptoms: Hematemesis (coffee ground → bright red), weakness, lightheadedness
• Allergies: None
• Medications: Spironolactone, lactulose, propranolol (non-compliant)
• PMH: Alcohol cirrhosis, known esophageal varices, prior variceal bleed
• Last Meal: Yesterday
• Events: Vomiting blood since morning

Physical Exam:

• General: Ill-appearing, jaundiced
• Abdomen: Distended (ascites), no tenderness, splenomegaly
• Rectal: Melena
• Stigmata of liver disease: Spider angiomata, palmar erythema, gynecomastia

Diagnosis

Upper GI hemorrhage - presumed variceal bleed in patient with known cirrhosis

Additional Management

Variceal Bleed Protocol:

• Octreotide 50mcg bolus, then 50mcg/hour infusion
• Ceftriaxone 1g IV (SBP prophylaxis in cirrhosis with GI bleed)
• PPI 80mg IV bolus, then 8mg/hour
• Emergent GI consultation for EGD
• Consider intubation for airway protection before EGD

Labs:

• Hemoglobin: 6.8 g/dL
• Platelets: 68,000
• INR: 2.1
• Total bilirubin: 4.2

EGD Findings:

• Large esophageal varices with active bleeding
• Band ligation performed
• Hemostasis achieved

Disposition

• ICU admission
• Continued octreotide x 5 days
• Transfusion to Hgb >7 (cirrhotics)
• Hepatology consultation
• Liver transplant evaluation discussion
• TIPS evaluation if rebleeds
• Discharged day 6 with propranolol, close follow-up

Central Line Complications to Know

Immediate:

• Arterial puncture
• Pneumothorax (IJ, subclavian)
• Hematoma
• Air embolism
• Arrhythmia (wire in heart)

Delayed:

• Infection (CLABSI)
• Thrombosis
• Catheter malposition

Teaching Points

1. Don't delay resuscitation for CVC: IO is fast and effective bridge
2. Site selection matters: Coagulopathy → avoid subclavian; pneumothorax risk assessment
3. Ultrasound guidance is standard: Reduces complications, improves success
4. Maximum barrier precautions: Reduces infection; full sterile field
5. Confirm venous access: Non-pulsatile blood, transduced waveform, ultrasound visualization
6. Femoral for emergencies: Fast, compressible, no pneumothorax; higher infection risk acceptable short-term
7. CVC allows vasopressors: Peripheral vasopressors only appropriate temporarily
8. Remove as soon as possible: Daily assessment of CVC necessity

Clinical Image

Image Description: Ultrasound image demonstrating femoral vein access with the needle visible entering the femoral vein (medial, compressible) with the femoral artery (lateral, pulsatile, non-compressible) visible for reference.

Attribution: Image from Wikimedia Commons, Ultrasound guided central line. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Ultrasound_guided_central_venous_catheterization.jpg

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