Yesterday’s question involved inserting a good old subclavian IV in a trauma patient with a clavicle fracture. Is there ever any reason to do it on the fractured side? As I mentioned, there’s no literature on this, just “feelings.”
Here’s my take:
- Landmarks – The usual anatomic landmarks (clavicle, first rib) may be out of place or non-palpable, making the procedure technically more difficult.
- Vessel location – The actual location of the vessels may have changed due to hematoma formation. This will decrease the likelihood of successful cannulation.
- Aspiration of blood – The usual way the trauma professional identifie if they have entered the vein is free aspiration of dark blood. A fresh fracture hematoma looks and feels exactly the same, and may be aspirated into the needle just as easily. So you think you’re in the vein, but you’re not.
- Contamination risk – There is the possibility that you may contaminate the fracture hematoma, leading to bone healing complications.
What if the fracture side is the lesser of two evils? Let’s say the contralateral side has even more severe injuries. I recommend abandoning the subsclavian approach on either side and choosing another site, like the internal jugular.
What if there’s a pneumothorax (occult or obvious) on the side of the clavicle fracture? Traditionally, we would choose that side for the line, because it may need a chest tube anyway and it removes any worry about causing a pneumothorax from the insertion procedure. In my opinion, that’s not a good enough reason to struggle with the four issues listed above.
Bottom line: Don’t even consider inserting a subclavian IV on the side of a clavicle fracture. The odds are stacked against you being successful, and there are essentially no benefits. Juice to squeeze ratio equals zero!
Hat tips to Corey Heitz and wasatch for their comments!
Related post: What do you think? Subclavian IV and clavicle fracture?
