Page 83 - JSOM Winter 2023

Effectiveness of Sternal Intraosseous Device
in Patients Presenting with Circulatory Shock

A Retrospective Observational Study

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Allyson M. Hynes, MD *; Shyam Murali, MD ; Gary A. Bass, MD, MBA, PhD ;
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Tareq Kheirbek, MD, ScM ; Zaffer Qasim, MD ; Naomi George, MD, MPH ; Jay A. Yelon, DO ;
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Kristen C. Chreiman, MSN ; Niels D. Martin, MD ; Jeremy W. Cannon, MD, SM 10
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ABSTRACT
Background: Hemorrhagic shock requires timely administra- Introduction
tion of blood products and resuscitative adjuncts through mul-
tiple access sites. Intraosseous (IO) devices offer an alternative Rapid intravenous (IV) access represents a crucial step in the
to intravenous (IV) access as recommended by the massive initial resuscitation of a trauma patient in extremis. Tactical
hemorrhage, A-airway, R-respiratory, C-circulation, and H- Combat Casualty Care (TCCC) emphasizes the need for vas-
hypothermia (MARCH) algorithm of Tactical Combat Casu- cular access in patients with evidence of hemorrhagic shock
alty Care (TCCC). However, venous injuries proximal to the during the circulatory phase of the MARCH (M-massive hem-
site of IO access may complicate resuscitative attempts. Ster- orrhage, A-airway, R-respiratory, C-circulation, and H-hypo-
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nal IO access represents an alternative pioneered by military thermia) algorithm. However, obtaining IV access can be
personnel. However, its effectiveness in patients with shock is arduous in patients with circulatory shock and venous shut-
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supported by limited evidence. We conducted a pilot study of down, delaying such resuscitation. Intraosseous (IO) device
two sternal-IO devices to investigate the efficacy of sternal-IO placement to bypass peripheral circulation has been recognized
access in civilian trauma care. Methods: A retrospective re- as an alternative strategy for immediate access and initial re-
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view (October 2020 to June 2021) involving injured patients suscitation of the injured patient. However, in patients with
receiving either a TALON or a FAST1 sternal-IO device multiple orthopedic and/or vascular injuries, IO infusions may
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was performed at a large urban quaternary academic medical extravasate into the soft tissues of extremities or into a central
center. Baseline demographics, injury characteristics, vascular body cavity before reaching the heart. Dismounted complex
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access sites, blood products and medications administered, blast injury represents one such injury pattern. The recent Af-
and outcomes were analyzed. The primary outcome was a suc- ghanistan and Iraq conflicts demonstrated a preponderance of
cessful sternal-IO attempt. Results: Nine males with gunshot such blast injuries from improvised explosive devices. Similar
wounds transported to the hospital by police were included to prior combat settings, more than 50% of casualties involved
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in this study. Eight patients were pulseless on arrival, and one injuries to extremities, including amputations.
became pulseless shortly thereafter. Seven (78%) sternal-IO
placements were successful, including six TALON devices and To circumvent extravasation into soft tissues or central cav-
one of the three FAST1 devices, as FAST1 placement required ity, an alternative approach using a sternal-IO device has been
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attention to Operator positioning following resuscitative identified to facilitate rapid and reliable initial resuscitation.
thoracotomy. Three patients achieved return of spontaneous In World War II, combat personnel had access to these devices
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circulation, two proceeded to the operating room, but none in their medical kits. The advent of the polyvinyl chloride in-
survived to discharge. Conclusions: Sternal-IO access was suc- travenous catheter led to the discontinuation of the IO until its
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cessful in nearly 80% of attempts. The indications for ster- resurgence in the 1970s. However, limited evidence supports
nal-IO placement among civilians require further evaluation the efficacy of the sternal-IO device in combat settings based

compared with IV and extremity IO access. on an autopsy reviewand findings involving healthy uninjured
military personnel. 4,5
Keywords: intraosseous; resuscitation; sternum; sternal in-
traosseous; sternal vascular access; vascular access By contrast, patients with high-energy blunt trauma or multiple
gunshot wounds may have limited sites for effective extremity
IV or IO access. Therefore, we sought to analyze the success
*Correspondence to ahynes@salud.unm.edu
1 Dr Allyson Haynes is a physician affiliated with the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA and the De-
partments of Emergency Medicine and Surgery at the University of New Mexico Health Sciences Center, Albuquerque, NM. Dr Shyam Murali,
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3 Dr Gary Bass, CDR Jay Yelon, and Dr Neils Martin are all physicians affiliated with the Division of Traumatology, Surgical Critical Care &
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Emergency Surgery in the Department of Surgery at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Dr Tareq
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Kheirbek is a physician affiliated with the Department of Surgery at Brown University Warren Alpert Medical School, Providence, RI. Dr Zaffer
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Qasim is a physician affiliated with the Department of Emergency Medicine at the University of Pennsylvania, Philadelphia, PA. Dr Naomi
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George is a physician affiliated with the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
8 Kristen Chreiman is affiliated with Division of Traumatology, Surgical Critical Care & Emergency Surgery in the Department of Surgery at the
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Col Jeremy Cannon is a physician affiliated with the Department of
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Surgery at the Edward Hébert School of Medicine in the Uniformed Services University, Bethesda, MD, and the Division of Traumatology, Surgi-
cal Critical Care & Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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