Subclavian vein catheterization in the emergency department: a comparison of guidewire and nonguidewire techniques.

Guidewire catheters have been used with increasing frequency during the last several years for placement of central venous lines. No data exist comparing success and complication rates of guidewire and nonguidewire catheterization in the emergency setting. A prospective, randomized study was conducted to compare GW and NGW central venous catheterization (CVC) by the infraclavicular subclavian approach. The study consisted of 210 patients (87 trauma, 123 medical) requiring a CVC as part of their emergency department care. Catheter placement and complications were determined by immediate chest radiograph, two-day followup, and chart review after discharge. Results demonstrated no statistically significant differences in success rates or complications, with the exception of catheter malfunction due to extrathoracic vascular placement or catheter kinkage. This complication occurred more frequently when the guidewire technique was used. The guidewire CVC technique does not appear to offer any improvement of complication rates when compared to the nonguidewire technique.

Emergency radionuclide scans.

Radionuclide diagnostic imaging is an important adjunct to the diagnosis and treatment of several conditions that present to the emergency department. The emergency physician should be able to properly apply these tests. A normal radionuclide perfusion lung scan can reliably rule out pulmonary embolism. The use of the radionuclide ventilation lung scan may help interpretation of a perfusion lung scan that is of intermediate probability for pulmonary embolism. A radionuclide venogram of the lower extremities is both sensitive and accurate for detecting the presence of deep venous thrombosis. A radionuclide testicular scan is invaluable in the workup of the acute scrotum, as long as the test is available in a timely manner and the diagnosis has not been established by another means. A multiple-gated acquisition cardiac scan can help make the diagnosis of cardiac contusion after other causes of cardiac instability have been corrected. The renal radionuclide scan is useful in the workup of obstructive uropathy, especially if intravenous pyelography is contraindicated. The hepatobiliary nuclear scan is able to help differentiate acute cholecystitis from other causes of right upper quadrant pain. Proper and timely use of these tests can prevent serious sequelae from a missed diagnosis, and in some cases eliminate the need for invasive tests, dangerous treatment, or even exploratory surgery when it is unwarranted.