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Prehospital central venous access is a procedure sometimes performed by advanced‐level paramedics, nurses, and EMS physicians. Usually in the form of a large 8.5 French single lumen catheter, the route provides rapid access to the central venous circulation for fluid resuscitation, blood product administration, and medications. Central venous access may be the preferable option when attempts at peripheral and IO lines have failed or are contraindicated, but its prehospital use is sparsely reported (Figure 8.7). Central venous line placement by air medical transport teams has been reported [22]. Similarly, one report documented the performance of 115 prehospital central lines placed by field‐response EMS physicians over a 3‐year period [23]. Another describes central venous catheters being placed in the prehospital setting quickly and safely by EMS physicians in systems that employ this model, such as those in Europe [24]. Critical care teams are often responsible for maintenance of these lines during interfacility transport, so familiarity with this form of vascular access is important.

The internal jugular, subclavian, and femoral veins are options for central venous access. Traumatic injuries above the diaphragm often dictate a femoral location. Attempts for access in the internal jugular and subclavian veins have a risk of pneumothorax, which should be considered if the patient acutely decompensates during the procedure. Placement of a central line, especially in the upper body, often causes an interruption of CPR efforts [21]. Risks of bleeding from venous or inadvertent arterial puncture, infection, thrombosis, and nerve damage also exist [19]. The prehospital environment makes it nearly impossible to preserve sterile technique. Given that these lines are performed as “code” lines under emergency, semisterile (similar to a peripheral IV line) conditions, it should be expected that the line would be removed and another one placed if the patient survives to the ED.

Figure 8.7 Central venous catheter kit.