ER Basics for Rookies

During a cardiac arrest, every second counts. The rookie dilemma: “Should I push drugs through a peripheral IV, get a central line, or go intraosseous?” Each route has pros and cons. The key is speed and reliability—the best line is the one that delivers drugs to the heart fastest and with the least delay.

Peripheral IV (PIV)

Pros

• Fastest and simplest if access already present.
• Easy to establish with minimal interruption to CPR.
• Safe, widely familiar technique.

Cons

• In low-flow states, drug delivery may be slower.
• Small, distal veins (hand, wrist) less reliable.
• Extravasation risk if poorly placed.

Pearls

• Use large-bore IV in antecubital or upper arm.
• Follow each drug with 20 mL flush + arm elevation to speed central delivery.

Central Venous Line (CVC)

Pros

• Delivers drugs directly to central circulation (SVC/RA).
• Reliable access for pressors if ROSC achieved.

Cons

• Takes too long during arrest (sterile prep, wire, dilation).
• Interrupts CPR, delays drug administration.
• Higher complication risk if rushed.

Pearls

• Not recommended as first-line in arrest.
• Place only if resuscitation prolonged and skilled operator available.
• After ROSC, central line may be placed for ongoing vasopressors.

Intraosseous Access (IO)

Pros

• Very fast, reliable when IV access fails.
• Any drug or fluid given IV can be given IO.
• Success rates high even in cardiac arrest.
• Excellent option for pediatrics and obese adults.

Cons

• Painful if patient awake (irrelevant in arrest).
• Slower flow for large volumes (needs pressure bag).
• Risk of extravasation, compartment syndrome (rare).

Pearls

• Common sites: proximal tibia, proximal humerus (humerus faster drug delivery).
• Go IO if no IV within 90 seconds or 2 attempts.
• Always flush after placement to ensure patency.

What the Guidelines Say

• AHA ACLS (2020):
  • Establish IV/IO access as soon as possible.
  • Peripheral IV first if readily available.
  • If IV not rapidly obtained, go IO—do not delay.
  • Central lines should not delay drug delivery.

Practical ED Approach

1. Check for existing IV access. If present → use it.
2. If no access after 2 attempts or 90 seconds → place IO.
3. Flush every drug with 20 mL saline (IV or IO).
4. Consider central line after ROSC if pressors required.

Common Rookie Mistakes

• Wasting precious minutes trying multiple IV attempts.
• Using small distal IVs (hand, wrist) for epi—delivery too slow.
• Forgetting to flush after drug administration.
• Delaying epinephrine while waiting for central line placement.
• Not having IO kit ready in the resus bay.

Rookie Pearls

• In cardiac arrest: fast > fancy.
• Peripheral IV works well if large and proximal—flush hard.
• IO is your safety net: reliable, quick, don’t hesitate.
• Central line has no role during active arrest unless code is prolonged and team is large.
• Always be thinking: “How do I get drugs to the heart the fastest, right now?”

Take-Home Message

In cardiac arrest, peripheral IV or IO are first-line.

• Peripheral IV: Use if already present or quickly obtained.
• IO: Go to this rapidly if IV fails.
• Central line: Not for the code—save it for ROSC.

For rookies: don’t freeze, don’t delay. Remember: “IV if easy, IO if not, central only after the code.”