The sternal IO and vascular access-any port in a storm.

Abstract

Attempting vascular access by out-of-hospital medical providers is one of the most common and important interventions performed. Hypovolemia, hypothermia, obesity, previous intravenous drug administration or abuse, burns, and amputations complicate the establishment of venous access. Failure rates have ranged between 10% and 40% and have taken upward and beyond 25 minutes to establish. Such delays deprive a patient of intravenous fluids, volume replacement, and medications and delay arrival at definitive care. Delay in intravenous access and preceding interventions are associated with higher morbidity and mortality rates. Establishing vascular access in 90 seconds, although widely considered an operational goal of out-of-hospital providers, is rarely achieved. These concerns raise a fundamental issue with regard to patient care and treatment: is it in the best interest of the patient to “load and go,” performing interventions in the air or ground unit under more difficult conditions, or should secure vascular access be a must-have priority before initiating transport? The FAST 1 intraosseous (IO) device has been recently described in the air medical literature. This new adjunct for achieving vascular access has proven beneficial for the following reasons: • Training is easy and takes a minimum of time. The skill can be practiced repeatedly until a level of proficiency has been achieved. • Application of the device is quick, with average insertion times of 77 seconds. • A high level of success (74%-95%) is achieved on first attempts. • Event-to-door time is reduced. • Patient outcomes improve when treated faster. • A high level of safety is provided for both the user and the patient. • Situations for which the device is “not recommended” are minimal. Inova AirCare added the FAST 1 sternal IO to the cache of equipment carried by flight crews. Our program is hospital based, and each flight crew consists of a flight nurse and flight paramedic. We perform approximately 40% scene and 60% interfacility transports. Flight nurse and paramedic training in IO was based on the manufacturer’s training outline, video manual, and insertion simulator. We demonstrated full compliance and validated flight personnel skills before adding the device. Existing medical protocols were revised to reflect inclusion of the device as an adjunct for establishing parenteral access. Within 30 days of adding the IO to our program, the device was used in an extraordinary clinical situation that was “not recommended” by the manufacturer. The flight crew decided to place the sternal IO after all other options for obtaining vascular access had been exhausted. Availability of the sternal IO was essential to the ability of prehospital care providers to deliver emergent care.