The femoral vein has a single approach. Palpate the

femoral artery 2 em below the inguinal crease. The vein

is usually 1 em medial to the artery at this location.

Insert the needle at a 45-degree angle to the skin, medial

to the femoral pulse, in a cephalad direction. In the

pulseless patient, palpate the anterior superior iliac spine

and the pubic tubercle. Draw an imaginary line connecting these 2 points. If this line is divided into thirds, the

vein will be located where the medial and middle thirds

intersect (Figure 3-6).

Figure 3-5. Subclavian vein catheterization.

(Reproduced with permission from Stone CK and

Humphries RL. Longe: Current Emergency Diagnosis

and Treatment. 57th ed. New York: McGraw-Hill,

2004-20 11. Figure 7-7.)

Empty space

Figure 3-6. Femoral vein anatomy. (Reprinted with

permission from Stone CK and Humphries RL. Longe:

Current Emergency Diagnosis and Treatment. 57th ed.

New York: McG raw-Hill, 2004-20 11. Figure 7-8.)

CHAPTER 3

COMPLICATIONS

Central venous access has multiple complications common

to each site, including bleeding, infection, arterial or

venous laceration, and air embolism. Site specific compli ­

cations include the following: for internal jugular, airway

compression from expanding hematoma, carotid artery

dissection, pneumothorax, and arrhythmia from cardiac

irritation; for subclavian, pneumothorax and arrhythmia;

for femoral, deep venous thrombosis, line sepsis, retroperitoneal bleeding, and bowel perforation.

SUGGESTED READING

Weber J, Schindlbeck M, Bailitz J. Vascular procedures. In: Simon

RR, Ross C, Bowman S, Wakim P. Cook County Manual of

Emergency Procedures. 1st ed. Philadelphia, PA: Lippincott

Williams & Wilkins, 20 12.

Wyatt CR. Venous and intraosseous access in adults. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka

RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY:

McGraw-Hill, 20 1 1.

Procedu ral Sedation

Pa ula E. Oldeg, MD

Key Points

• Procedural sedation is the admin istration of analgesic

and sedative agents to induce a depressed level of

consciousness so that a medical procedure can be performed without patient movement or memory.

INDICATIONS

Procedural sedation is a clinical technique that creates a

decreased level of awareness, but allows maintenance of

protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide

analgesia, amnesia, and anxiolysis during a potentially

painful or frightening procedure. Pharmacologic agents

used in procedural sedation are of 3 general classes: seda ­

tives, analgesics, and dissociative agents. The use of such

medications in the emergency setting is common and has

been shown to be safe. Before the procedure, the physician

should assess the patient for systemic disease and for a