AbstractIntroduction: Access to the vascular system of the critically ill or injured adult patient is essential for resuscitation. Whether due to trauma or disease, vascular collapse may delay or preclude even experienced medical providers from obtaining standard intravenous (IV) access. Access to the highly vascular intramedullary space of long bones provides a direct link to central circulation. The sternum is a thin bone easily identified by external landmarks that contains well-vascularized marrow. The intraosseous (IO) route rapidly and reliably delivers fluids, blood products, and medications. Resuscitation fluids administered by IV or IO achieve similar transit times to central circulation. The FAST-1 Intraosseous Infusion System is the first FDA-approved mechanical sternal IO device. The objectives of this study were to: (1) determine the success rate of FAST-1 sternal IO device deployment in the prehospital setting; (2) compare the time of successful sternal IO device placement to published data regarding time to IV access; and (3) describe immediate complications of sternal IO use.Methods: All paramedics in the City of Portsmouth, Virginia were trained to correctly deploy the FAST-1 sternal IO device during a mandatory education session with the study investigators. The study subjects were critically ill or injured adult patients in cardiac arrest treated by paramedics during a one-year period. When a patient was identified as meeting study criteria, the paramedic initiated standard protocols; the FAST-1 sternal IO was substituted for the peripheral IV to establish vascular access. Time to deployment was measured and successful placement was defined as insertion of the needle, with subsequent aspiration and fluid flow without infiltration.Results: Over the one-year period, paramedics attempted 41 FAST-1 insertions in the pre-hospital setting. Thirty (73%) of these were placed successfully. The mean time to successful placement was 67 seconds for 28 attempts; three of the 31 insertions did not have times recorded by the paramedic. Paramedics listed the problems with FAST-1 insertion, including: (1) difficulty with adhesive after device placement (3 events); (2) failure of needles to retract and operator had to pull the device out of the skin (2 events); and (3) slow flow (1 event). Emergency department physicians noted two events of minor bleeding around the site of device placement.Conclusion: This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as a first-line device to obtain vascular access in the critically ill or injured patient. The FAST-1 sternal IO device can be a valuable tool in the paramedic arsenal for the treatment of the critically ill or injured patient. The device may be of particular interest to specialty disaster teams that deploy in austere environments.
Multimodality Monitoring: Toward Improved Outcomes
