Page 138 - JSOM Spring 2023

correctly. We hypothesized that paramedics would also have dif- most common sites used are the proximal humerus, proximal tibia,
ficulty accurately identifying the proper location for NT. Meth- and sternum. Sternal IO placement remains an often-overlooked
ods: A prospective, observational study was performed to assess option in emergency and prehospital medicine. Due to the con-
paramedic ability to identify the location for treatment with NT. flicts in Afghanistan and Iraq, the use of sternal IOs have increased.
Participants were recruited during a statewide Emergency Medical Methods: The authors conducted a limited review, searching the
Services (EMS) conference. Subjects were asked the anatomic site PubMed and Google Scholar databases for “sternal IO,” “sternal
for NT and asked to mark the site on a shirtless male volunteer. intraosseous,” and “intraosseous,” without specific date limitations.
The site was copied onto a transparent sheet lined up against pre- A total of 47 articles was included in this review. Results: Sternal
determined points on the volunteer’s chest. It was then compared IOs are currently FDA approved for ages 12 and older. Sternal IO
against the correct location that had been identified using palpa- access offers several anatomical, pharmacokinetic, hemodynamic,
tion, measuring tape, and ultrasound. Results: 29 paramedics par- and logistical advantages over peripheral intravenous and other IO
ticipated, with 24 (83%) in practice for more than five years and points of access. Sternal IO use carries many of the same risks and
23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) limitations as the humeral and tibial sites. Sternal IO gravity flow
reported training in NT, although six (21%) had never performed rates are sufficient for transfusing blood and resuscitation. In addi-
a NT in the field. Nine paramedics (31%) recognized the second tion, studies demonstrated sternal IOs are safe during active CPR.
ICS at the MCL as the desired site for NT, with 12 (41%) spec- Conclusion: The sternal IO route remains underutilized in civilian
ifying only the second ICS, 11 (38%) specifying second or third settings. When considering IO vascular access in adults or older
ICS, and six (21%) naming a different location (third, fourth, or children, medical providers should consider the sternum as the rec-
fifth ICS). None (0%) of the 29 paramedics identified the exact ommended IO access, particularly if the user is a novice with IO
second ICS MCL on the volunteer. Mean distance from the second devices, increased flow rates are required, the patient has extremity
ICS MCL was 1.37-cm (interquartile range [IQR]: 0.7-1.90) in trauma, or administration of a lipid soluble drug is anticipated.
the medial-lateral direction and 2.43-cm in the superior-inferior
direction (IQR: 1.10-3.70). Overall mean distance was 3.12cm Military experience in the management of pelvic
from the correct location (IQR: 1.90-4.50). Most commonly, the fractures from OIF/OEF
identified location was too inferior (93%). Allowing for a 2-cm Parker W, Despain RW, Bailey J, Elster E, Rodriguez CJ, Bradley M
radius from the correct position, eight (28%) approximated the BMJ Mil Health. 2020-001469.
correct placement. 25 (86%) were within a 5-cm radius. Conclu-
sion In this study, paramedics had difficulty identifying the correct Introduction: Pelvic fractures are a common occurrence in combat
anatomic site for NT. EMS medical directors may need to rethink trauma. However, the fracture patterns and management within
training or consider alternative techniques. the most recent conflicts, i.e., Operation Enduring Freedom (OEF)
and Operation Iraqi Freedom (OIF), have yet to be described, es-
Intraosseous access in the resuscitation of pecially in the context of dismounted complex blast injury. Our
trauma patients: a literatura review goal was to identify the incidence, patterns of injury, and manage-
Tyler JA, Perkins Z, De’Ath HD. ment of pelvic fractures. Methods: We conducted a retrospective
Eur J Trauma Emerg Surg. 2021;47(1):47–55. review on all combat-injured patients who arrived at our military
treatment hospital between November 2010 and November 2012.
Purpose: Intraosseous (IO) catheters continue to be recommended Basic demographics, Young-Burgess fracture pattern classification,
in trauma resuscitation. Their utility has recently been debated due and treatment strategies were examined. Results: Of 562 patients
to concerns regarding inadequate flow rates during blood transfu- identified within the study time period, 14% (81 of 562) were
sion and the potential for haemolysis. The objectives of this review found to have a pelvic fracture. The vast majority (85%) were
was to examine the evidence for intraosseous catheters in trauma secondary to an improvised explosive device. The average Injury
resuscitation and to highlight areas for future research. Methods: Severity Score for patients with pelvic fracture was 31 ± 12, and
A PubMed and Embase search for articles published from Janu- 70% were classified as open. Of the 228 patients with any trau-
ary 1990 to August 2018 using the terms (“intra-osseous access” matic lower extremity amputation, 23% had pelvic fractures, while
or “intraosseous access” or “IO access”) AND trauma was per- 30% of patients with bilateral above-knee amputations also sus-
formed. Original articles describing the use of an IO catheter in tained a pelvic fracture. The most common Young-Burgess injury
the resuscitation of one or more trauma patients were eligible. pattern was anteroposterior compression (APC) (57%), followed
Animal, cadaveric studies, and those involving healthy volunteers by lateral compression (LC) (36%) and vertical shear (VS) (7%).
were excluded. Results: Nine studies, comprising 1218 trauma Only 2% (nine of 562) of all patients were recorded as having pel-
patients and 1432 device insertions, were included. The insertion vic binders placed in the prehospital setting. 49% of patients with
success rate was 95% and the incidence of complications 0.9%. pelvic fracture required procedural therapy, the most common of
Flow-rate data and evidence of haemolysis were poorly reported. which was placement of a pelvic external fixator (34 of 40; 85%),
Conclusion: Intraosseous catheters have high insertion success followed by preperitoneal packing (16 of 40; 40%) and angio-
rates and a low incidence of complications in trauma patients. embolisation (three of 40; 0.75%). 17 (42.5%) patients required
Existing evidence suggests that IO transfusion is not associated combinations of these three treatment modalities, the majority of
with haemolysis; however, further studies in humans are needed. which were a combination of external fixator and preperitoneal
There is a paucity of Flow-rate data for blood transfusion via IO packing. The likelihood to need procedural therapy was impacted
catheters in this population, although much anecdotal evidence by injury pattern, as 72% of patients with an APC injury, 100% of
advocating their use exists. patients with a VS injury, and 25% of patients with an LC injury
required procedural therapy. Conclusions: Pelvic fractures were
Sternal intraosseous devices: review of the literature common concomitant injuries following blast-induced traumatic
Jared A. Laney, MSN, RN, FNP-BC; Jonathan Friedman, BSN, lower extremity amputations. APC was the most common pelvic
RN, FP-C; Andrew D. Fisher, MD, LP fracture pattern identified. While procedural therapy was frequent,
West J Emerg Med. 2021;22(3):690–695. the majority of patients underwent conservative therapy. However,
placement of an external fixator was the most frequently used mo-
Introduction: The intraosseous (IO) route is one of the primary dality. Considering angioembolisation was used in less than 1% of
means of vascular access in critically ill and injured patients. The cases, in the forward deployed military environment, management

136 | JSOM Volume 23, Edition 1 / Spring 2023