Elsevier

Injury

Volume 45, Issue 1, January 2014, Pages 77-82
Injury

IV access in bleeding trauma patients: A performance review

https://doi.org/10.1016/j.injury.2012.12.026Get rights and content

Abstract

Background

Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay.

Methods

We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion.

Results

Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p < 0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6–30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p < 0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p = 0.12).

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.

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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