One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?
The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.
The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?
A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.
Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.
- Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
Alright, here’s the final answer to the xray I posted last Friday. This patient was using a ThermaCare Menstrual HeatWrap by Pfizer. It was applied to her back, though, for relief from back pain. It was not apparent during the trauma activation exam, even with clothes off, until we logrolled her to examine her back.
Each pocket in the wrap contains a granular mixture of activated carbon, iron powder, salt and a few other ingredients. When the wrap is removed from its vacuum pouch it heats up to 104F (40C) and stays hot for up to 8 hours. The iron shows up on xrays. The regular pattern is a giveaway that this is not some other problem (stones, drug pouches in the colon).
Bottom line: Remember, conventional xrays collapse a 3D space onto a 2D image, so you can’t tell how deep objects are (anterior to posterior). This is another reminder to be thorough when examining your patient. They can hide things anywhere!
Disclaimer: I do not have any financial or other interest in Pfizer Inc.
Remember that weird pelvic xray with the unidentifiable item on it last week? Click here to review it. Lots of interesting guesses came in on this one. Two people got close, but not close enough.
Here’s a picture of what we found when we logrolled the patient to examine the back. See if you can figure it out and leave a comment before I post the complete answer later this morning.
I’d like to thank everyone for their comments. An unregistered user just left a comment on a post on local wound exploration that I published 6 months ago. It poses a good question and I don’t want it to get lost in the archives. Click here to see the old post. I’m going to do a post next Wednesday entitled “The Art of Local Wound Exploration” that should answer everybody’s questions about this.
And so far, no one has figured out the weird pelvic xray below.
Here’s a perfect item for April Fool’s Day, although it is for real. The xray below was a pelvic image obtained during a trauma team activation. I’m not going to give you any more information than that.
You’ve got until Monday to figure out what’s doesn’t belong and give me an answer in the comments. I’ll post the full story and answer then.