Central Venous Access in Trauma Bay

Advanced Trauma Life Support (ATLS) principles during the primary survey emphasize the need for resuscitation by controlling haemorrhage and restoring the intravascular volume by administration of warm isotonic fluids/blood products, which necessitate insertion of large-bore intravenous lines and central venous catheterization (CVC) if difficulties are encountered in the former. Achieving central venous access in a trauma bay is challenging. The most commonly catheterized sites are the femoral (most preferred), internal jugular and subclavian veins. CVC in trauma patients is challenging when compared to non-emergent areas or elective settings. The femoral veins are compressible and hence appropriate for coagulopathic patients, and their insertion does not interfere with concomitant management of the airway and breathing. Positioning the patient, an altered anatomy in view of traumatic injuries and immobilization devices increase complications like catheter misplacements, vascular injuries and bloodstream infections. Ultrasound-guided central line placement thus increases the success rate and reduces complications. Central venous catheters can later be used for parenteral nutrition, haemodynamic monitoring and temporary transvenous pacing. In cases in which prolonged use of central venous catheters is contemplated, the need for reinsertion at alternate sites is needed in cases where the femoral vein has been catheterized, and the same needs to be done within 48 hours to minimize the risk of thrombosis and infection.