Page 34 - JSOM Fall 2023

Combat Vascular Access

A Scoping Review

Shane Smith, MD, MSc *; John White, MD ; Tabitha McGuire, MD ;
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Bethann Meunier, MD ; Ian Ball, MD, MSc ; Richard Hilsden, MD, MBA 6
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ABSTRACT
Medical leadership must decide how to obtain vascular access headings and keywords: infusions, intraarterial, intraosseous,
in a combat environment. Adequate combat trauma resusci- intravenous, subcutaneous, catheterization, central venous,
tation requires efficient vascular access. A search of the Med- blood transfusion, intravascular drug administration, intraos-
line and EMBASE databases was conducted to find articles on seous drug administration, blood vessel catheterization, fluid
combat vascular access. The primary dataset of interest was resuscitation, combat, military medicine, military personnel,
the type of vascular access obtained. Other data reviewed in- warfare, armed conflict, and battlefield. Searches were restricted
cluded who performed the intervention and the success rate of to humans and adults. No language restrictions were applied.
the intervention. The search strategy produced 1,339 results, Studies of vascular and IO access performed in the prehospital
of which 24 were included in the final analysis. Intravenous combat environment were included. Studies were excluded if
(IV), intraosseous (IO), and central venous access have all been the patients were less than 18 years old, if it was an animal
used in the prehospital combat environment. This review sum- study, or if it was a case report or review article. The type of
marizes the available combat literature to help commanders access obtained, type of provider performing the intervention,
make an evidence-based decision about their prehospital vas- and success and complication rates were recorded. We did not
cular access strategy. limit the dates of our review. All studies were uploaded into
Cochrane’s Covidence.org reference management system. This
Keywords: intravenous access; vascular access; interosseus review was registered with PROSPERO (CRD42021207114).
access; central venous catheters
All studies were subject to a title and abstract review by two
independent examiners (JW, TM). In this step, obviously ir-
relevant studies were excluded. A third party was used to re-
Introduction
solve conflicts (SS). Remaining studies were subject to full text
The prehospital combat environment poses unique challenges screening. Data were extracted from study text, tables, and
and deserves specific study. Whereas in a civilian environment, figures, when necessary.
there is a growing body of evidence that quick evacuation to
surgical care is paramount, the military prehospital provider Results
may not be afforded that option. Tactical environment, enemy
threats, and limits on available transportation may necessitate The search resulted in 1,339 studies, 10 of which were dupli-
prolonged field care (PFC). Interventions such as tranexamic cate studies and were removed. Abstract screening removed
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acid (TXA), freeze-dried plasma, and blood products may 1,229 studies, leaving 100 studies for full text review. Full text
need to be administered by the combat prehospital provider review excluded 76 more, leaving 24 studies for inclusion (Fig-
near the point of injury. To administer these agents, IV or IO ure 1-Prisma Diagram). Sixteen papers reported on IV access
access must be acquired in the prehospital combat environ- in combat (Table 1). Six papers reported on tibial IO access
ment. The purpose of this scoping review is to evaluate the (Table 2), two papers reported on humeral access (Table 3),
available literature describing prehospital access techniques and four papers reported on sternal access (Table 4). Twelve
that have been used in combat, the provider level of training, papers reported on IO access but did not specify the location
and their success rate. This review will inform military medical of the catheter (Table 5). Two papers described pre-hospital
leadership’s mission planning. central line placement (Table 6).

Intravenous Access
Methods
From the 16 papers included in this review, there were a total
We conducted a search in Medline and EMBASE databases. The of 5,898 patients with attempted IV access. Three papers re-
search terms included the following combinations of subject ported on the success rate (1,842 patients).
*Correspondence to shane.smith@lhsc.on.ca
1 Dr Shane Smith and Dr Richard Hilsden are affiliated with the Royal Canadian Medical Service, Ottawa, ON, Canada, and the Department of
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Surgery, University of Western Ontario, London, ON, Canada. Dr John White is affiliated with the Royal Canadian Medical Service, Ottawa,
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ON. Dr Tabitha McGuire is affiliated with the Royal Canadian Medical Service, Ottawa, ON, Canada, and the Division of Emergency Medicine,
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McMaster University, Hamilton, ON, Canada. Bethann Meunier is affiliated with the Royal Canadian Medical Service, Ottawa, ON, Canada,
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and the Department of Anesthesia and Perioperative Medicine, Queen’s University, Kingston, ON, Canada. Dr Ian Ball is affiliated with the
Royal Canadian Medical Service, Ottawa, ON, Canada, and the Departments of Medicine, Epidemiology, and Biostatistics at the University of
Western Ontario, London, ON, Canada.
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