ACLS Provider: Course

Vascular Access

Establishing vascular access is a crucial component of Advanced Cardiac Life Support (ACLS), allowing for the rapid administration of medications, fluids, and blood products during resuscitation efforts. Timely vascular access is essential for delivering life-saving interventions and improving patient outcomes. Two primary methods are utilized: intravenous (IV) and intraosseous (IO).

Types of Vascular Access:

Peripheral Intravenous (IV) Access

Peripheral IV access is the most common and often the first-line approach for establishing vascular access in emergency situations. It involves inserting a catheter into a peripheral vein, typically in the arm (antecubital fossa, forearm, hand) or, less commonly, the leg (saphenous vein). Peripheral veins are relatively easy to locate and cannulate, making this a quick and efficient method in many cases. However, in patients with circulatory collapse, hypotension, or significant edema, locating and cannulating peripheral veins can be challenging or impossible.

Intraosseous (IO) Access

Intraosseous access provides a rapid and reliable alternative when peripheral IV access is difficult or cannot be obtained quickly. This technique involves inserting a specialized needle into the bone marrow cavity, which provides direct access to the systemic venous circulation. The proximal tibia (below the knee) and proximal humerus (upper arm) are the preferred insertion sites. Medications, fluids, and blood products administered via the IO route reach the central circulation almost as quickly as through a central venous catheter. IO access is particularly valuable in critically ill patients, children, and situations where time is of the essence.

Steps for Establishing Vascular Access:

Peripheral IV Access:

  1. Select an appropriate vein: Start distally (hand or forearm) and move proximally if necessary. Palpate and visualize the vein.
  2. Apply a tourniquet proximal to the chosen site to distend the vein.
  3. Cleanse the insertion site with antiseptic solution.
  4. Insert the catheter at a shallow angle, advancing it into the vein.
  5. Confirm placement by observing flashback of blood in the catheter hub.
  6. Advance the catheter over the needle, remove the needle, and connect the IV tubing.
  7. Secure the catheter in place with appropriate dressing and tape.

IO Access:

  1. Select the appropriate insertion site (proximal tibia or humerus).
  2. Cleanse the insertion site with antiseptic solution.
  3. Stabilize the bone and insert the IO needle using a rotary motion until a "pop" or loss of resistance is felt, indicating entry into the medullary cavity.
  4. Remove the stylet and confirm placement by aspirating bone marrow (although this is not always possible) and by easy infusion of fluids without significant resistance.
  5. Secure the IO needle in place.

Key Points Regarding Vascular Access:

  • Peripheral IV access remains the preferred initial approach when easily obtainable due to its relative ease of insertion and provider familiarity.
  • IO access is a critical and life-saving alternative when peripheral IV access is delayed, difficult to obtain, or unsuccessful after several attempts. It should be considered early in the resuscitation process in critically ill patients.
  • After establishing either IV or IO access, it is crucial to flush the line with normal saline after administering medications to ensure complete delivery into the circulation and to prevent medication interactions within the tubing.
  • For IO access, be aware of potential complications such as compartment syndrome and osteomyelitis, although these are rare with proper technique.