Page 85 - JSOM Winter 2023

TABLE 1 Baseline Demographics Including Injuries and Survival TABLE 2 Patient Presentation and Injury Details*
Outcomes 1 PDO, uncertain time of injury; DOA; GSW: chest × 2, back × 1,
Entire Cohort, groin × 7, thigh × 4. Injuries: right ventricle laceration extends
no. (%)*; n=9 to spine and right ventricle outflow tract, posterior mediastinal
Baseline Demographics structures with palpable bone fragments in the base of the
wound from the spinal canal.
Age, y, median (IQR) 26 (24–31) 2 PDO, uncertain time of injury; DOA; GSW: left chest, right
Male 9 (100) chest × 2, left shoulder, back × 3; Injuries: bilateral pulmonary
Penetrating-gunshot wound 9 (100) hilar injury, left AV junction.
Glasgow Coma Scale, median (IQR) 3 (3–3) 3 PDO, uncertain time of injury; DOA; GSW: left hip and right
hip/thigh, left maxilla, left lateral posterior neck; Injuries:
Injury Severity Scale, median (IQR) 26 (17–75) transection of right iliac artery and several enterotomies.
Patients with a head/neck injury 3 (33) 4 PDO, lost pulses in trauma bay; GSW: left lateral neck with
Patients with a thoracoabdominal injury 8 (89) bullet fragment involving right mandible; Injuries: left vertebral
Patients presenting with a potential extremity artery and fractured spinous process.
injury † 8 (89) 5 PDO, uncertain time of injury; DOA; GSW: right shoulder,
Patients presenting with 1 potential right hip, multiple right thigh, left thigh and peripheral GSWs:
extremity injured 4 Injuries: right upper lobe, right axillary or subclavian vessel,
with unidentified mediastinal and abdominal injuries.
Patients with 2 potential extremities injured 2
6 PDO, uncertain time of injury; DOA; GSW: left clavicle, left
Patients with 3 potential extremities injured 1 thigh, left knee, multiple peripheral; Injuries: left subclavian
Patients with 4 potential extremities injured 1 artery and vein, penetrating,
Outcomes 7 PDO, uncertain time of injury; DOA; GSW: left chest × 2,
Return of spontaneous circulation 3 (33) right posterior shoulder, left posterior shoulder, left
temple, several bilateral groin, thigh, several peripheral.
Operating room intervention 2 (22) Injuries: multicompartment intracerebral hemorrhage with
6-hour survival 1 (11) intraventricular hemorrhage, left lung and left thoracic inlet.
Discharge survival 0 (0) 8 PDO, uncertain time of injury; DOA; GSW: left hip, right
*Unless otherwise specified. gluteal, left flank × 2, left thigh ×3; Injuries: right ventricle,
right lung, right diaphragm, right liver.
† As patients died before the diagnosis of injured extremities was estab-
lished, the potential injuries are listed. 9 PDO, uncertain time of injury; DOA; GSW: back × 5, right
axilla; Injuries: right lung, diaphragm, and abdominal injuries.
Patients’ presenting characteristics, gunshot wound locations, *No extremity injuries are repeated with their respective reported in-
and wound characteristics based on physical examination are juries. AV = atrioventricular; DOA = dead on arrival; GSW = gunshot
listed in Table 2. Six patients (67%) received a TALON IO wound; PDO = police drop off.
device while three (33%) received a FAST1 IO. Seven (78%)
sternal-IO devices were successfully inserted (Table 1). All six Consequently, goals of care were changed. Two of the patients
(100%) TALON IO devices were successfully inserted, while who obtained ROSC went to the operating theater. The two
one (33%) of the FAST1 IOs was successfully deployed, as the patients (patients 3 and 4) were transfused with more than
unsuccessful ones were visually malpositioned. 60 units of blood products (Table 3). One of these patients
survived for at least six hours; however, this patient died of
Seven sternal-IO devices were deployed by the trauma faculty. coagulopathy. The other patient succumbed to possible refrac-
Additionally, the trauma patients were managed by three dif- tory vasoplegic and neurogenic shock.
ferent personnel. Our trauma leader, who has military training,
inserted five sternal-IO devices, four of which were success- Discussion
ful. The other two personnel had no prior military training.
One of the Operators placed a sternal-IO device successfully. Despite a rich historical military experience during World War
The other Operator supervised two successful attempts and II of routine placement of IO catheters, including sternal-IO
attempted a third unsuccessfully. Two of the devices were suc- placement, and an increasing number of studies documenting
cessfully deployed by emergency department faculty. the use of sternal-IO devices in both the modern military sec-
tor and research/cadaver laboratories, limited data support
6,7
A list of comprehensive modes of intravascular access is pre- their effectiveness in patients with hemorrhagic shock. In
sented in Table 3, including the total amount of fluids and this pilot study, we investigated a novel application of military
medications infused through all sites of access. Notably, seven resuscitation in a civilian population at risk for potentially
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(78%) patients had at least one tibial-IO device placed during preventable death from trauma. We sought to determine
their resuscitation. Six (67%) patients had tibial-IO access whether the sternal-IO device was a plausible mode of resus-
that was potentially impeded by either a potential proximal citation in patients with multiple gunshot wounds who are at
venous injury or a potential underlying fracture. A total of high risk for difficult and obstructed extremity IV access. In
10 tibial-IO devices, three humeral-IO devices, two femoral this study, sternal-IO placement was successful in nearly 80%
central line catheters, and four peripheral IVs were potentially of cases, indicating a potential role in mitigating hemorrhagic
impeded. However, two tibial-IO devices, one humeral-IO de- shock in the civilian sector.
vice, none of the central lines, and three peripheral IVs were
unimpeded (Table 4). An 80% success rate is consistent with the prior two decades
of preexisting literature, consisting of a compilation of cadaver,
Three (33%) of the patients achieved ROSC while in the military, and prehospital studies. 4,5,16–17,18–22 However, these
trauma bay, although one had a non-survivable traumatic sternal-IO devices have never been studied in patients with
brain injury (multi-compartmental intracerebral hemorrhage). severe traumatic injury in extremis. Cadavers encompassed

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