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may extravasate from nearby vessels (e.g., the internal mam- placement, infusion rates, and outcomes. These findings may
mary vessels); however, this is not a known absolute contra- then have civilian applications beyond the use of sternal-IO
indication. Further, our division did not observe any overt devices for impeded access, such as during a mass casualty in-
extravasation. cident. These findings could then have a profound impact on
resuscitation during both in-hospital and prehospital trauma
The strength of our study is that it combined details from our care and represent a potential mechanism to mitigate prevent-
initial product trial and performance improvement review able death. This would reinforce military–civilian partnership
along with a structured manual chart review, to discuss the in innovative trauma care.
temporal events surrounding the placement of the sternal-IO
device. Nonetheless, our analysis is not without inherent lim- Conclusion
itations. First, as a single-center pilot study, our analysis was
limited to only nine patients. This limited our ability to detect In this single-center, retrospective observational pilot study in-
any meaningful statistical significance. Second, our population volving an urban civilian academic trauma center, deploying
was limited to patients in the arrest/peri-arrest period, yield- the sternal-IO device in a mangled exsanguinating patient pop-
ing poor survival outcomes, as expected. Therefore, our find- ulation was associated with a high success rate, which can be
ings cannot be extrapolated to patients outside of the arrest/ translated to combat causality care. Furthermore, sternal-IO
peri-arrest period. Additionally, the success rate of the FAST1 access facilitates the administration of products and adjunc-
IO would have likely been higher had the devices not been tive therapies into the central circulation while avoiding sev-
placed in patients undergoing an EDT. Lastly, as a retrospec- eral potential impeded locations. Future studies are necessary
tive review, data were collected for clinical reasons. Thus, we to characterize the civilian trauma patient who would most
were unable to make any meaningful comparisons regarding benefit from this intervention and to determine performance
the modes of intravascular access placement. For example, we parameters relative to other access strategies.
could not delineate the flow rate of the sternal-IO device, the
access site through which the products were infused, or the Author Contributions
amount of time required to insert the device. AMH, KCC, NDM, and JWC designed the study. AMH, SM,
ZQ, and JAY searched the literature. AMH collected the data.
Our pilot study showed that sternal-IO devices were deployed AMH analyzed the data. AMH, GAB, TK, NG, and JWC par-
successfully nearly 80% of the time. All sternal-IO devices ticipated in data interpretation. AMH, SM, and JWC drafted
were deployed by physicians; while this may limit generaliz- the article. All authors critically revised and approved the
ability, our success rates correlated with those of other prac- manuscript.
titioners. 16,17,19,20,22 An alternative would be the other modes
of intravascular access. Chreiman et al. compared IO access Disclaimer
with central venous catheters and peripheral intravenous cath- The views in this article are those of the authors and do not
eters. Their findings indicated that IO access had a higher represent an endorsement by or the views of the United States
23
success rate than both the central venous catheters (46%) and Navy, the United States Air Force, the Department of Defense,
23
peripheral intravenous catheters (42%). Additionally, their or the United States Government.
findings noted that the IO placement was quicker than the
placement of a central venous access catheter. Disclosures
The authors have no personal or institutional interest with re-
Other studies reported that the success rate of the sternal-IO gards to the authorship and/or publications of this manuscript.
device (71%–95% was similar to those of both tibial-IO (91%–
100%)and humeral-IO devices (77%–83%). 4,5,16–20,22–24 How- Funding
ever, when comparing the sternal-IO device with other modes Teleflex provided both the TALON IO and FAST1 IO devices
of IO access, these studies fail to highlight cases where the without cost. However, they did not participate in the design
venous injury may be interposed between the vascular access of the study, analysis of the data, interpretation of the data or
site and the heart. Although humeral-IO devices are in greater drafting/revising of the manuscript.
proximity to the heart than tibial-IO devices, the flow speed
of humeral-IO devices often limits the speed of resuscitation. References
The sternal-IO device addressed this limitation with a faster 1. Committee on Tactical Combat Casualty Care (CoTCCC). Tac-
documented flow rate than the humeral-IO device in two ca- tical Combat Casualty Care (TCCC) Guidelines for Medical Per-
daver studies. 17,25 Thus we sought to determine the plausibility sonnel. Available at: https://books.allogy.com/web/tenant/8/books/
of the sternal-IO device, when the patient had other possible b729b76a-1a34-4bf7-b76b-66bb2072b2a7. Published online De-
sites of IO access. In addition, our pilot study used both a man- cember 15. Accessed 20 March 2023.
ual insertion device, TALON IO, and an impact-driven device, 2. Engels PT, Passos E, Beckett AN, Doyle JD, Tien HC. IV access in
FAST1 IO. One may consider a handheld, battery-powered bleeding trauma patients: a performance review. Injury. 2014;45
(1):77–82. DOI:10.1016/j.injury.2012.12.026.
device, such as the Arrow EZ-IO (Teleflex, https://myteleflex 3. Lewis P, Wright C. Saving the critically injured trauma patient: a ret-
.com); however, the evidence does not strongly support bat- rospective analysis of 1000 uses of intraosseous access. Emerg Med
tery-powered sternal-IO devices over either of these devices, J. 2015;32(6):463–467. DOI:10.1136/emermed-2014-203588.
which would be a target for further investigation. 26 4. Harcke HT, Crawley G, Mazuchowski E. Feedback to the field: an
assessment of sternal intraosseous (IO) infusion. J Spec Oper Med.
2011;11(1):23–26.
The sternal-IO device has the potential to benefit an exsan- 5. Bjerkvig CK, Fosse TK, Apelseth TO, et al. Emergency sternal in-
guinating casualty. With a nearly 80% successful placement traosseous access for warm fresh whole blood transfusion in dam-
rate, we believe future prospective trials should be performed age control resuscitation. J Trauma Acute Care Surg. 2018;84(6S
to better capture its potential impact, including the time of Suppl 1):S120–S124. DOI:10.1097/TA.0000000000001850.

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