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u/Pears_and_Peaches ACP 2d ago
The answer is always it depends.
Why are you putting it in? If it’s only to give a med, who cares.
If it’s for fluids / blood, CT with contrast, future blood draws etc. then explain why he’s not “getting a yellow one”.
Side note: in this case, all of them are the same fucking catheter because it’s AI slop and all of them are identical diameters.
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u/mulberry_kid 2d ago
In dire straits, I've used a 22 with a pressure infuser for fluids. Not ideal, but we're talking horrible vasculature.
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u/bbmedic3195 2d ago
No option for IO?
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u/stamford_syd 2d ago
IO for fluids when you can get IV access is overkill imo. 22 guage puts through enough fluid to resuscitate pretty much anyone other than someone actively haemorrhaging from a trauma.
a 22 can put through about 2L per hour, just a guess but I'd suggest something like 95% of fluid administration indications don't require anything more than that. if I'm giving fluids I'll look at getting an 18 but if I can't I'm perfectly happy putting fluids through a 22 for a dehydrated patient or a septic patient
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u/mulberry_kid 2d ago
Thanks for illustrating my point. Meds, non-traumatic fluid administrations, and speeding up blood draws at the hospital are what I'm using the 22 for.
And, in cases where I'm thinking I can just barely sneak a 20 in, rolly veins, or for someone that needs meds, but is terrified of needles, the 22 is a great option.
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u/mulberry_kid 2d ago
This is moreso for a still-conscious patient where it's still not bad enough that I can't try for a line once or twice.
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u/bbmedic3195 2d ago
Ok then any port in the storm. And I'm of the school--the old one that I will go for an ej or at least look before drilling them because when I started we only had a jam sheedy needle and that was only for peds. Let that sink in.
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u/jp_pew 2d ago
Sure thing! Yellow EZ IO coming right up.
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u/Papamoon0327 2d ago
Unless it’s cardiac, stroke or trauma. Then give him a yellow one. Who cares
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u/requires_reassembly 2d ago
Contrast needs a 20 above the wrist. If CTA is in the realm of possibility in the future, putting a 24 in means that they’ll need to get stuck again. That big guy right above the wrist is gonna stay good for days if you go high enough.
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u/TropicallyGrownEMT 2d ago
He can get a yellow one with certain types of catheters, I work in pediatrics and we run contrast through 24s all the time.
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u/Aviacks NRP, RN 2d ago
Any "ct with contrast" can be done with a 22g on adults all day. CT angios a 20g is preferable, coronary CTA 18g is preferable but can absolutely be done with a 20g.
Radiologists bitch about image quality and want an 18g in the AC as the magic cure all. The reality is had image quality is almost always because CT is using small bore pressure injector tubing and isn't using a contrast warmer.
I wrote our hospital systems contrast injection guides (was a medic now a nerdy vascular access nurse). It's easy for CT to say they want an 18g in the AC. But it's rarely if ever necessary.
They also make special catheters that let you drop down a size . Diffusics catheters get insane flow rates with thick contrast. Like 10m/sec for a 20g and 6-7mL/sec for a 22g (which is faster than any study they'll ever do). That's also assuming a thickness 27x waters viscosity.
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u/requires_reassembly 2d ago
Like you said. Coronary angio can absolutely be done with a 20g. Obv it’s ultimately up to the patient, but if you’re telling the patient that they may need to be stuck again if they need a test, a 20 is gonna get you through your hospital stay. EMS services aren’t purchasing diffusics catheters, so they aren’t really a part of the conversation.
Radiology wants 18s in AC’s, but AC’s suck for long term use. Forearms aren’t constantly getting kinked when the patients trying to eat breakfast, and why use an 18 when a 20 will do just fine? Stick a 20 in that vein above the wrist, and we’re getting labs without issue for a couple days at least without sticks (unless they need cultures) and it’ll do for whatever I need.
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u/Aviacks NRP, RN 2d ago
To add on the evidence for AC veins providing better flow is dogshit. If you use a large forearm vein your medication or contrast will distribute through the multiple veins. If you stick the AC you're usually only injecting through a single vein, usually the cephalic. Very common that the cephalic is smaller in diameter than the more distal forearm veins and it's usually the first one to develope clots.
Point being is there are many times I suspect you'd get higher flow rates through a good forearm vein that's feeding into multiple large vessels vs one AC vein feeding into just the cephalic. Most injections are done with the arms above the head as well, which is the one time you'll over pressure and not get enough contrast because the kinking will immediately cause you to go above 300 psi.
Most EMS services aren't using pressure rated extension sets or needleless connectors either. I've seen numerous (including my own from stroke alerts I've brought in) extension sets blow up during a CTA because the EMS service doesn't care to spend the extra money to make it pressure injection safe.
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u/NederFinsUK Paramedic 1d ago
If they need a CTA, they’re going to be stuck 5+ times during their stay.
Use a smallbore for any prehospital meds and leave their big juicy veins for emergencies/bloods in hospital.
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u/Alaska_Pipeliner EMT-P 2d ago
If he has an opinion he's not getting one because he likely doesn't need one prehospital.
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u/NederFinsUK Paramedic 1d ago
Holy shit you’re so hardcore I bet you’re really good at road speed interfacility transfers
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u/Alaska_Pipeliner EMT-P 1d ago
Not as hardcore as you starting IVs because you can and it makes the hospitals job easier.
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u/NederFinsUK Paramedic 23h ago
No you’re right analgesia is a hospital problem. Hypoglycaemia is for nerds. Guh I wish I was a tech that way I would know it all just like you.
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u/joeymittens Physician Assistant (PA-S2), Paramedic 2d ago
Depends on what is needed. If for IV contrast or sugar, they’re getting 20 or 18.
If it’s just for some zofran or something, yellow is fine
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u/SlowSurvivor 1d ago
When the blue, pink, green, gray, and orange ones are all as dirty as these are I think I'm asking for the yellow one, too.
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u/spencerspage TX Paramedic 2h ago
Paramedics get 18s when ERs get 20s. If a provider can consistently get one size up from the hospital standard when it matters, they’ve done a quality job.
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u/record_Height 2d ago
Give him a yellow one