r/emergencymedicine • u/hey_nurse18471 ER RNBN • 2d ago
Discussion Art lines
Hey everyone. I’m a ER nurse and I’m just getting my feet wet with critically ill patients.
We had a massive trauma come in the other day where the patient broke all their limbs, except for one arm. We transferred the patient to our stretcher and switched over all the medication and got them on the monitor. The patient arrived via air ambulance. Upon transferring the patient, I did not realize they had an art line in their upper arm because there was an automatic BP cuff covering it. Not realizing it was an art line, I took the cuff off and replaced it with our BP cuff to take a blood pressure.
I then realized he had an art line because another nurse took the cuff off and plugged in the art line. I have absolutely no hands on experience with art lines, so I didn’t not recognize what it was. Art lines really intimidate me.
So my question: is there any patient safety risk with obtaining a BP over an arm that has an art line? I’m genuinely feeling like such an idiot not recognizing it.
36
u/Mobile-Bus-9921 2d ago
I mean in the grand scheme of all of the fuck ups most people here have done (myself included), considering yours didn’t even cause any harm, I wouldn’t worry too much about it. Now this has happened I bet you’ll remember to look for the rest of your career, lol.
5
19
u/StLorazepam RN, CFRN 2d ago
I wouldn’t beat yourself up over it, an upper arm art line is rare, and should have been mentioned by someone before transferring them so it doesn’t pull out when you switch gurneys.
There probably isn’t a lot of information for BP cuffs over art lines, but I would assess the site, see if it draws blood, and see if the readings and wave forms are accurate with the art line and go from there.
https://onepagericu.com/a-lines This is my favorite art line cheat sheet.
11
u/HistoricalMaterial Flight Nurse 2d ago
A lines are not a big deal. But they'll feel that way until you've seen a few. You'll get there. Just keep doing what youre doing. Ask questions and stay curious. Comfortability will come with time.
32
5
u/kiki9988 2d ago
I had a nurse put a BP cuff on a type III open humerus fracture a few months ago 🙃🥴. So long as you don’t do something like that, you’re good.
The biggest risk with putting a BP cuff over the Aline is that with time, that line is probably going to get dislodged. I can’t think of a scenario where it’d directly harm the patient though.
4
u/LunarSoul ED Attending (not that ED) 2d ago
That doesn't make sense, where was the A-line placed? A-lines in the upper extremity can be placed in the radial artery by the wrist, or by the armpit in the axillary artery. If the blood pressure cuff that came with the patient was covering the A-line, was it in the mid arm? (Which would not be good.)
Anyway, no there shouldn't be much issue taking a pressure once or twice. The cuff inflation can transiently occlude arterial inflow proximal to the radial A-line. While the cuff is above systolic pressure, the radial arterial waveform distal to the cuff will usually become markedly damped or disappear, so you may see a “flat” or near-flat A-line tracing. It is not a meaningful arterial pressure during that time. It may not be perfectly flat because collateral flow through the ulnar artery/palmar arch or local pressure changes can persist. This is consistent with how cuffs work: they inflate above systolic and then deflate while detecting pressure oscillations, temporarily altering limb blood flow.
In the axillae you may not see any changes in A-line pressures.
Repeated cuff cycling on the same limb as an A-line should be avoided when there is a alternative, because they already carry risks such as thrombosis, spasm, bleeding, catheter kinking/dislodgement, and distal ischemia; guidelines emphasize frequent distal circulation checks for compromised color, circulation, or motion.
You should not be intimidated by A-lines... They're not complicated.
9
u/Danskoesterreich ED Attending 2d ago
Probably brachial artery.
0
u/LunarSoul ED Attending (not that ED) 2d ago edited 2d ago
Never seen them done outside of some cardiac surgery settings. The risk does not outweigh the benefits when you can go higher up and get better collateral blood flow (or choose a different site like femoral). I've heard of a limb lost due to a brachial A-line once at one of my hospitals.
7
1
u/WhyDoYouPostGarbage Critical Care Physician 5h ago
There is no added risk when you know how to safely perform the procedure… it’s the same as a subclav CVC. I regularly do brachials, sometimes it’s the only viable option.
1
u/LunarSoul ED Attending (not that ED) 4h ago
I personally teach to avoid the brachial for A-lines. Yes I know they can be done, but given the poor collateral, risk of injury to the media nerve, and the risk of ischemic complications, there are safer alternatives like axillary, radial, or femoral. I guess I need to look at the literature again, but that SICU article highlights that they had significant complications.
https://jtd.amegroups.org/article/view/17076/html This one says low risk in perioperative/cardiac surgery papers.
Can't find any high quality evidence to support or avoid, but I know when I teach residents (who often don't have the best mechanical technique), I would avoid brachial for that reason also.
4
u/HistoricalMaterial Flight Nurse 2d ago
A Lines are a problem for a lot of ED RNs in early career. This post is extremely unsurprising. Some EDs dont place them at all, or very rarely. Frequency begets comfortability.
3
u/HockeyandTrauma Trauma Team - BSN 2d ago
Throughout my ED career, we constantly asked our educator to keep A-Lines in the yearly competency because at least there'd be some stuff to reference back, because we see them only occasionally. In the 10ish years I was there, I think they included them 3 or 4 times.
2
u/Tumbleweed_Unicorn ED Attending 1d ago
This is very location dependent. In residency, the ER placed art lines on every ICU patient. Since then, I've worked at places where could if I wanted to in the ER and I've worked places where we don't even have an art line kit...
1
u/hey_nurse18471 ER RNBN 6h ago
Yes it was, it was on the patients inner bicep. I noticed after that the transducer was taped to the patient’s shoulder. I never even knew an art line could be placed there. This patient was really critical and we had just minutes to get them transferred, meds established, chest tube secured because it was open, foley established and put on our monitors, to the CT scanner then to the OR to secure the airway because they came criked because oral intubation wasn’t possible. So things were moving FAST.
1
u/Nearby_Maize_913 ED Attending 2h ago
the majority of A lines are not necessary and way more risk than benefit
-2
u/-ThreeHeadedMonkey- 2d ago
No point measuring bp at all imo when there's an arterial line unless maybe it malfunctions.
54
u/sgw97 ED Resident 2d ago
Don't think there's any risk of harm to the patient, you might just fuck up the art line though