IV access in bleeding trauma patients: A performance review
Introduction
Exsanguinating haemorrhage is the most common cause of trauma mortality in the first hour after arrival to a trauma centre and accounts for almost one half of the deaths in the first 24 h.1, 2, 3 The treatment of exsanguinating haemorrhage involves (1) the immediate treatment with simple measures (i.e., direct pressure, splinting, tourniquet, and pelvic binding) and subsequent definitive control of bleeding via surgical or interventional radiological means as appropriate; (2) the correction of any coagulopathy; and (3) resuscitation with intravenous fluids and blood products. While haemorrhage control remains the cornerstone of the definitive management of haemorrhagic shock in trauma patients, intravenous infusion of crystalloid and blood products remains the mainstay of the resuscitation of these bleeding patients. Thus, timely and adequate intravenous access is of paramount importance to the actively bleeding trauma patient. Furthermore, in the evolving world of “damage control resuscitation”4 which mandates the early use of larger volumes of plasma and platelets in addition to red blood cells, obtaining early and adequate intravenous access5 can be a rate-limiting step in providing this life-saving6 therapy.
According to the most recent ATLS guidelines,7 “access to the vascular system must be obtained promptly. This is best done by inserting two large-calibre (minimum of 16 gauge) peripheral intravenous catheters before placing a central venous line is considered”. ATLS guidelines further state that “a minimum of two large-calibre intravenous (IV) catheters should be introduced” with the “[preference being]…establishment of upper-extremity peripheral IV access”.7 No other guidance exists in ATLS. While the American Heart Association Guidelines8 and European Resuscitation Council Guidelines9 both describe intraosseous as options in those where IV access is unobtainable, there are no guidelines that expound on the necessary timing and successive steps to be taken in obtaining adequate intravenous access in trauma patients. Difficulty obtaining IV access in non-trauma emergency department (ED) patients10 has been described but limited data exist about the actual time required to obtain IV access in trauma patients. Obtaining intravenous access in the field may be associated with longer transport times in bleeding trauma patients,11, 12 which may have an adverse effect on outcome.2 The development of intra-osseous devices presents a potentially viable alternative in difficult patients, both in the prehospital and emergency room setting.
We performed a retrospective cohort study of bleeding patients at our institution (requiring uncrossmatched blood in the trauma room) to characterise the timing and nature of intravenous access achieved in these patients. We hypothesised that obtaining prehospital peripheral IV access delays transport to the trauma centre. Furthermore, we postulated that obtaining prehospital peripheral IV would not improve timely transfusion of blood products or outcomes.
Section snippets
Methods
Our study was approved by the Research Ethics Board of the University of Toronto.
Results
During the study period, 5505 patients were assessed by the trauma team, with 3145 of these arriving to hospital directly from the scene of injury. Of these, 208 patients received at least one unit of uncrossmatched PRBCs in the trauma room, and constituted our study group. Baseline characteristics of the study group are shown in Table 1. Overall, this was a young group of patients who were mostly males, who had predominantly suffered blunt injury, who were critically injured, and required
Discussion
Achieving intravenous access takes time. In our study, we demonstrated that achieving a prehospital IV was associated with a scene time which was almost 5 min longer, consistent with previous studies.11, 12, 13, 14 Delays in transport to a trauma centre have been shown to adversely affect outcomes15, 16 in some studies. Streamlining prehospital care such that placement of IVs and Advanced Life Support care is provided only during patient transport and thus does not prolong scene time, has been
Conclusions
We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge. Strategies to improve patient care include
Contributors
Authors Engels and Tien contributed to the conception and design of the study. Authors Engels, Passos, Becket, and Doyle contributed to data acquisition. Authors Engels and Tien contributed to data analysis and interpretation. All authors contributed to the critical revision of the manuscript and gave final approval for its publication.
Funding
The study did not receive any funding.
Conflict of interest
None of the authors have any financial conflicts of interest to disclose.
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Cited by (18)
Emergency Transfusions
2020, Emergency Medicine Clinics of North AmericaCitation Excerpt :When assessed in a study of 200 participants, prehospital time was prolonged in patients when IV access was obtained in the prehospital setting.9 Additionally, there was no improvement in the time to transfusion upon hospital arrival.9 Therefore, it is recommend that, particularly in situations with short prehospital times, the goal should be to expedite transportation, with a scoop-and-run approach.
Prehospital use of peripheral intravenous catheters and intraosseous devices: An integrative literature review of current practices and issues
2020, Australasian Emergency CareCitation Excerpt :The review does not show that the profession of the person inserting the PIVC has an impact; particularly on the prevalence of insertion or use. Those services primarily staffed by medical staff report insertion rates of 55% and 58% which while higher than some, may be expected as these services would see higher acuity patients, is also lower than those studies reporting on high acuity patient groups [25,35,36,40]. This suggests two potential influences on device insertion by medical practitioners.
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2014, British Journal of AnaesthesiaCitation Excerpt :In 2013, Engels and colleagues found obtaining pre-hospital i.v. access was associated with longer EMS on-scene and pre-hospital times; 16.1 vs 11.4 min and 18.9 vs 16.5 min, respectively. Obtaining i.v. access in patients arriving to the ED without pre-hospital i.v. required 20.5 min for peripheral and 21.7 min for central line access.35 The concept of ‘hypotensive resuscitation’ for patients with uncontrolled haemorrhage is based on the theory that overzealous fluid resuscitation, apart from further hindering the coagulation system, can potentially increase bleeding by interrupting delicate blood clots formed by the increased arterial pressure.
Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review
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