Your patient in the Emergency Department has a Zone II or Zone III finger amputation which requires primary closure of the wound prior to discharge with appropriate outpatient follow up. However, a protruding piece of bone often prevents closure of the skin flap and requires trimming by using a rongeur. While this process is typically carried out by an orthopedic or hand surgical consultant, this post aims to introduce the use of a ronguer during management of finger amputation in the Emergency Department.
Case: A 68 year old woman presents to the ED with fever, hypotension, and AMS. She has a PICC in place. Your overzealous intern places a central line, and he swears the stick was venous. You obtain and CXR to confirm line placement. Where does the line terminate?
Answer: B. It is venous but extends to the right brachiocephalic vein. The central line is inadvertantly deep and likely resulted from the guidewire being displaced by the patient's PICC line. This patient will need the line removed/replaced.
Estimated Central Line Lengths for Correct Placement:
Right Internal Jugular Vein: 13 cm, +/- 2 cm
Right Subclavian Vein: 15 cm, +/- 2 cm
Left Internal Jugular Vein: 15 cm, +/- 2 cm
Left Subclavian Vein: 17 cm, +/- 2 cm