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  • Print publication year: 2008
  • Online publication date: January 2010

4 - Establishing Vascular Access in the Trauma Patient

    • By Matthew A. Joy, Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, Donn Marciniak, Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, Kasia Petelenz-Rubin, Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
  • Edited by Charles E. Smith, Case Western Reserve University, Ohio
  • Publisher: Cambridge University Press
  • DOI:
  • pp 69-80



Describe in a structured approach the advantages and disadvantages of various types of intravascular access and infusion devices in the trauma patient.

Present practical guidelines for the establishment of central venous access in the critically injured patient.

Describe in detail the technique for insertion of various central access sites, with current standard of care recommendations in the trauma patient.

Describe the relevancy of peripheral arterial cannulation in the trauma setting.

Present current recommendations regarding intraosseous access in the trauma patient.


Advanced Trauma Life Support (ATLS) guidelines recommend that, in the initial management of hemorrhagic shock, prompt access must be obtained [1]. This is best accomplished by the insertion of two large-caliber (16 G angiocaths or larger) peripheral intravenous (IV) catheters before consideration is given to central venous catheters, or venous cutdowns [1]. Obviously, the condition of the arriving trauma patient, that is, massive extremity injury and extent of the injury, may not allow for any reasonable peripheral venous access for IV insertion. This chapter reviews the management of intravascular access in the trauma patient in the hospital setting where definitive care is to be provided. The main areas to be covered include venous access as well as arterial access in critically injured patients. Clinical experience and evidence-based medicine is balanced to provide a framework for guiding the management of patients from a vascular access standpoint.


Prior to arrival in the emergency department, PIV cannulation has usually been performed in the field by prehospital personnel [1, 2].

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