Introduction
Access to the vascular system of a 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. It is especially challenging to establish IV access in the prehospital setting due to limitations imposed on the paramedic by the condition of the scene. In addition, it is not feasible for paramedics to obtain central venous access or perform peripheral venous cut-down if peripheral IV access cannot be established.
Drinker was the first to examine intraosseous (IO) infusion in 1922,Reference Drinker, Drinker and Lund1 and today, IO infusion is a well-established alternative to IV infusion. The use of the tibial IO device is accepted widely in the pediatric population, and now is a standard part of the American Heart Association's Pediatric Advanced Life Support (PALS) textbook.
Access to the highly vascular intramedullary space of long bones provides a direct link to central circulation. The sternum is a thin bone identified easily by external landmarks that contains well-vascularized marrow. The IO route can deliver fluids, blood products, and medications rapidly and reliably. Certain resuscitation drugs attain comparable pharmacokinetic parameters whether administered IV or IO.Reference Orlowski, Porembka and Gallagher2 Resuscitation fluids administered by IV or IO achieve similar transit times into central circulation, as demonstrated by radionuclide tracer studies.Reference Cameron, Fontanarosa and Passalaqua3 The FAST-1 Intraosseous Infusion System (Pyng Medical Corporation, Vancouver, Canada) is the first US Food and Drug Administration-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
The Institutional Review Board at the Eastern Virginia Medical School approved this study and waived written informed consent by study participants.
Study Materials and Training
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. Education included a one-hour instructional video and a simulated FAST-1 deployment and removal to appreciate the pressure required to insert the device. The deployment technique followed the instructions in the device user's manual.4 In addition, study investigators showed nurses at the two receiving emergency departments how to care for and remove the sternal IO.
Subjects and Device Deployment
The study subjects were critically ill or injured adult patients in cardiac arrest who were treated by paramedics during a one-year period. When a patient was identified as meeting study criteria, the paramedic initiated Advanced Cardiac Life Support (ACLS) or Advanced Trauma Life Support (ATLS) protocols; the FAST-1 sternal IO was substituted for the peripheral IV to establish vascular access. Time to deployment was measured with a stopwatch provided with study materials. Time started when the plastic bag containing the FAST-1 was opened, and time stopped at successful placement of the sternal IO. Successful placement was defined as insertion of the needle, with subsequent aspiration and fluid flow without infiltration.
Data Collection
After arrival at the emergency department, the paramedic and the attending emergency department physician completed data sheets regarding the deployment of the device.
Results
Over a one-year period, paramedics from the City of Portsmouth, Virginia attempted 41 FAST-1 insertions in the prehospital 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 problems with FAST-1 insertion, which included: (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.
Of the 11 unsuccessful attempts, seven failed because the FAST-1 did not deploy. There were two events of infiltration after placement, after which the FAST-1 was not used for patient resuscitation. One attempt resulted in inability to aspirate; this patient had a history of coronary artery bypass surgery. One attempt failed because although the needles were inserted, the catheter did not deploy.
Discussion
This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as the first-line device to obtain vascular access in the critically ill or injured patient. Previous studies describing the prehospital use of the FAST-1 only have initiated FAST-1 deployment if one or more IV insertion attempts failed.Reference Horwood, Adams and Tiffany5–Reference Macnab, Christenson and Findlay7 The paramedics in the current study achieved a one-year 73% success rate for sternal IO placement after one training session. This percentage is well within the range of published success rates of 72 to 84%.Reference Horwood, Adams and Tiffany5–Reference Macnab, Christenson and Findlay7 It also has been shown that as providers become more experienced with the FAST-1, success rates improve.Reference Macnab, Christenson and Findlay7 The average time to obtain vascular access, 67 seconds, also was within previously reported times of 64 to 77 seconds.Reference Horwood, Adams and Tiffany5,Reference Macnab, Christenson and Findlay7
Past experience with critically ill or injured patients illustrates the difficulty experienced by providers at all levels with peripheral access. Rossetti et al reviewed 66 pediatric emergency department arrests at a children's hospital;Reference Rossetti, Thompson and Aprahamian8 24% of patients did not have IV access for ≥10 minutes, and 6% of patients never had a working IV established. The findings in the current study suggest that providing them with a simple and quick alternative to peripheral IV access can reduce valuable time spent by paramedics prior to emergency department arrival. This may result in improved patient outcomes, as successful resuscitation has been correlated with shorter total time spent in the prehospital setting.Reference McSwain, Garrison and Artz9
Conclusions
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. The benefit of the FAST-1 sternal IO device in such a setting is that there are no batteries or any other moving parts or pieces to get lost or be misplaced. It is a single self-contained unit that operates on simple push power. This would make this particular device much more desirable for teams that have large caches of equipment with low turnover, such as large disaster response teams and tactical paramedic teams. In the authors' case, the City of Portsmouth Police Department's Tactical Response Unit paramedics now carry this device as standard equipment after this trial.
Abbreviations:
IO = intraosseous
IV = intravenous
