Page 38 - JSOM Fall 2023

attempt was made on one patient but was unsuccessful. The Central Venous Catheter
overall success rate of patients receiving a tibial IO was 60%. Two papers report on central line placement. DuBose et al.
In a subsequent manuscript, Nadler et al. described 30 patients described a forward surgical team placing 15 central lines in
who underwent IO insertion following unsuccessful attempts a total of 173 patients (8.7%). The forward surgical team
4
2
at IV access. A 50% success rate for tibial IO was reported. included a surgeon, an emergency medicine physician, a reg-
Vassallo et al. (Camp Bastion, Afghanistan) reported on 21 istered nurse anesthetist, and a physician assistant. These
8
tibial IO insertions. They reported an overall success rate of central lines were used for blood products, TXA, analgesia,
95%. Cooper et al. reported success rates of tibial IO insertion sedation, antibiotics, and antiemetics. Tobin et al. (Afghani-
9
by the UK Defense Medical Service in Afghanistan. Three pa- stan) reported on three central line placements during inflight
tients had a tibial IO attempted in the prehospital setting. air evacuations from point of injury. Neither paper reported
11
on any complications.
Complications were reported in the Cooper and Vassallo pa-
pers. These were identified in one study and included pain, Discussion
needle fracture with fragment retention, “needleless inser-
8,9
tion,” and a bent needle. Indications for IO were reported in Trauma patients benefit from urgent evacuation to surgical
two papers (Cooper et al. and Schauer et al.), which included care. Unfortunately, the combat environment may require pro-
blood products, crystalloid, induction agents for intubation, longed field care or delayed evacuation. Prehospital combat
analgesia, antibiotics, sedation, antiemetics, TXA, and vaso- providers may be required to obtain intravascular or intra-
pressors. 9,10 The provider type was reported in three papers osseous access for resuscitation, sedation, or other therapies.
(Cooper et al., Nadler et al., and Schauer et al.) and included
physicians, registered nurses, paramedics, medics, and first This literature shows that IV access has a high success rate in
responders. 7,9,10 the combat prehospital environment. In the two largest series,
the identified the success rates were 82% (Nadler et al., 2015)
Sternal Intraosseous and 93% (Maddry et al., 2016). Nadler discovered that the
2,3
Four papers report on sternal IO insertion, on a total of 129 majority of success was obtained in the first two attempts.
patients.
Tibial and sternal IO access has been used extensively in com-
Harcke et al. published a descriptive autopsy case review on 98 bat, with humeral access being less common. For the two
27
sternal IO insertions. They utilized post-mortem CT imaging papers reporting exclusively on patients from the prehospi-
to identify whether placement was successful. Eighty-one cases tal combat environment, the tibial IO could be established
had sternal IOs in place, and in three of these cases, the tip of in 50% (15/30) and 60% (18/30) of patients, with some re-
the needle was outside of the sternum. In 18 cases, there was quiring multiple attempts. The single paper that described
2,7
evidence of needle holes, but no device in place; these were prehospital sternal insertion reported a success of 79%. Ca-
likely unsuccessful attempts. This would yield a success rate of daveric studies demonstrated appropriate placement of sternal
78 out of a total 98 cases (80%). IOs in 80% of cases with three needles outside of the sternal
cortex; this is concerning for potential mediastinal or cardiac
Vassallo et al. (Camp Bastion, Afghanistan) recorded 24 ster- injury. Humeral IO insertion success was reported in one pa-
8
nal IO insertion attempts. Nineteen of these (79%) were suc- per as 83%.
cessful. There was one case of device fracture upon removal
that did not affect ability to function prior to removal. The Based on these data, we recommend the following algorithm
providers that performed the sternal IO insertions included for prehospital vascular access. The most reliable and success-
medical officers, medics, and first responders. The indications ful means to achieve access is peripheral IV cannulation. We
for sternal IO placement were administration of crystalloid, recommend two attempts at IV cannulation should be con-
blood products, antibiotics, paralytics, sedatives, vasopressors, ducted. If these are not successful, then IO access should be ob-
antiemetics, and TXA. Complications that have been reported tained. Combat literature does not report on dislodgement of
include retained needle tip, and needle tip outside the body of IO during transport. However, civilian data suggest tibial IOs
the sternum. are less likely to be dislodged than humeral (5.8% vs. 33%).
12
This is in keeping with the authors’ experience. We would sug-
Humeral Intraosseous gest attempting tibial IO insertion after failed IV cannulation.
Two papers report on humeral IO insertion (Schaeur et al. and If there is suspected thoracic or intra-abdominal injury, or
Vassalo et al.) on a total of 71 humeral IO insertions. significant lower extremity injury, humeral IOs are preferred.
Due to the potential for mediastinal injury from sternal IOs
Vassallo et al. (Camp Bastion, Afghanistan) recorded 66 inser- extremity IOs should be first line (Figure 2). 13
tion attempts of humeral IOs. Fifty-five of these were success-
8
ful (83%). Reported complications included intra-articular Central venous catheters have been used successfully by phy-
insertion and breaking of the device upon removal, resulting sicians in the forward environment. In the special case of pro-
in a retained needle. viders with advanced training and central line experience, they
can be considered.
Schauer et al. (Operation Inherent Resolve) reported on 5
patients with humeral IO insertion. No success rate was Conclusion
10
reported. Providers who inserted the IOs were physicians,
paramedics, and medics. Indications for access were adminis- This scoping review suggests that IV cannulation is the preferred
tration of crystalloids, blood products, antibiotics, paralytics, method of prehospital vascular access in the combat environ-
sedatives, vasopressors, antiemetics, and TXA. ment. IO techniques should be used as rescue interventions.

36 | JSOM Volume 22, Edition 3 / Fall 2023