Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review

Ryan P. Dumas, From the Division of Burn Trauma Acute and Critical Care Surgery (R.P.D., A.M.), UT Southwestern Medical Center, Dallas TX; Division of Acute Care Surgery (M.A.V., P.H.), University of Rochester Medical Center, Rochester, NY; Division of Acute Care Surgery (A.W.M., C.R.E., B.M.B.), Vanderbilt University Medical Center, Nashville, TN; Sunnybrook Health Sciences Centre (L.T.L., D.P.), Toronto, Canada; Section of Trauma, Acute Care Surgery and Critical Care (E.Q., C.G.V.), University of Colorado, Aurora, CO; Trauma and Acute Care Surgery (N.B., J.M.), University of Arkansas for Medical Sciences, Little Rock, AR; Traumatology, Surgical Critical Care and Emergency Surgery (D.F.B.), University of Pennsylvania, Philadelphia, PA; George Washington University, Center for Trauma and Critical Care (J.E., J.A.Z.), Washington, DC; Texas Health Harris Methodist (A.A., S.M.), Fort Worth, TX; Methodist Medical Center (H.M.G.V., M.T.), Dallas, TX; Acute Care Surgery, Trauma, and Surgical Critical Care (S.B., J.M.), University of Kansas, Kansas City, KS; UC Davis Medical Center-Trauma, Acute Care Surgery and Surgical Critical Care (S.L., D.L.), Sacramento, CA; NYU Langone Health, NY (L.K., M.B.); University of South Alabama (N.M.P., A.H.M.), Mobile, AL; Division of Trauma, Acute Care and Critical Care Surgery (R.S., S.B.A.), Penn State Health Medical Center, Hershey PA; John Peter Smith Health (T.H., F.O.M.), Fort Worth, TX; Sanford Health (P.B., J.G.), Sioux Falls, SD; Reading Hospital Tower Health (S.M., B.F.D.), Reading, PA; Baylor University Medical Center (J.M., K.H.), Dallas TX; and Division of Trauma and Acute Care Surgery (D.N.H.), Medical College of Wisconsin, Milwaukee, WI.
Michael A. Vella
Amelia W. Maiga
Caroline R. Erickson
Brad M. Dennis
Luis T. da Luz
Dylan Pannell
Emily Quigley
Catherine G. Velopulos
Peter Hendzlik
Alexander Marinica
Nolan Bruce
Joseph Margolick
Dale F. Butler
Jordan Estroff
James A. Zebley
Ashley Alexander
Sarah Mitchell
Heather M. Grossman Verner
Michael Truitt
Stepheny Berry
Jennifer Middlekauff
Siobhan Luce
David Leshikar
Leandra Krowsoski
Marko Bukur
Nathan M. Polite
Ashley H. McMann
Ryan Staszak
Scott B. Armen
Tiffany Horrigan
Forrest O. Moore

Document Type

Journal Article

Publication Date

7-1-2023

Journal

The journal of trauma and acute care surgery

Volume

95

Issue

1

DOI

10.1097/TA.0000000000003958

Abstract

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Department

Surgery

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