IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.
But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.
This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).
During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.
Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!
[Note to prehospital providers: please comment below or email with your experience using this position.]
In my last post, I discussed the only paper I could find on the lateral trauma position (LTP). It was a survey that was taken 5 years after implementation of this transport position in Norway. Is there anything else out there that may help give us guidance on proper positioning during transport?
Just this month, a paper was published that tries to look at this issue from a different viewpoint. Since we can’t really show that the LTP is good or prove that it is truly safe, can we at least demonstrate that supine positioning might be bad?
A very diverse group of researchers in Norway performed a systematic literature review and meta-analysis of everything they could find published on supine positioning and airway patency in unconscious trauma patients, especially when compared to lateral positioning. This was carried out from the beginning of time, or 1959 in this case.
See if you can follow their progress:
There weren’t really any good studies using this global search, so they broadened it to include trauma patients with decreased level of consciousness.
Oops! There weren’t any studies using this broader definition, either.
The authors wanted to use morbidity and mortality as their outcomes. But, there weren’t any good studies for this either so the decided to use indirect outcomes such as hypoxia, hypercapnea, hypoventilation, work of breathing, and a bunch of other stuff.
Oops again! There weren’t any studies reporting these indirect outcomes.
But when these two indirect searches were combined, a number of papers (20) were identified that were used for a meta-analysis
A number of these papers showed soft results (language like ”indication of”, “small difference”). The only significant results were found in patients with known obstructive sleep apnea.
Bottom line: The use of the lateral trauma position is an intriguing concept, and has been used successfully in Norway for about 10 years. Intuitively, it makes sense, especially in obese patients or those with known obstructive sleep apnea. Unfortunately, this paper approached the questions asked kind of backwards, in my opinion.
I believe that LTP has a place in prehospital care, but that there will be significant barriers to adoption in most countries. In order to overcome these hurdles, clear protocols and positioning instructions will need to be developed, as well as specific indications. And it wouldn’t hurt to do a few good studies along the way. The Norwegians have helped us with the ethics questions, as it is the standard of care in that country. So write your local IRB and get busy!
Reference: Is the supine position associated with loss of airway patency in unconscious trauma patients? A systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 23:50, July 1, 2015.
Here’s a kick in the head, unless you are one of my Norwegian readers.
In the US and many (most) other countries, trauma patients are routinely transported strapped down in the supine position. It’s tradition. It’s easy. It gives prehospital providers pretty good access for whatever they need to do.
But it is right? Some patients, particularly those who have a diminished level of consciousness or severe obstructive sleep apnea, or both, may not do well in that position. In 2005, Norwegian Emergency Medical Services (NEMS) introduced the use of the lateral trauma position (LTP) across the country. Here is how it looks:
Five years later, a group from several hospitals across Norway conducted a survey of all ground and air EMS providers in the country. A few factoids:
This one year survey included 202 of 206 ground EMS stations and 23 of 24 air EMS stations. Questionnaire response rate was about 50%
Of supervisors at ground EMS units, 75% said that they had implemented LTP
67% of ground units had written policies for use and 73% had provided training
Individual ground provider opinions were a bit different. 89% were familiar with LTP, but only 58% actually used it.
Training seemed to be the key. Of ground providers given training, 86% were confident in using LTP, but of those not given training, only 58% were.
Only 53% of air services used LTP, and only one had a protocol.
Here are the instructions on how to do it:
Bottom line: Interesting concept. Unfortunately there is little (or no) objective data to help us. The main thing available now is a 10 year experience with the lateral trauma position in Norway, and I have not seen any analyses of it. In my next post, I’ll review a meta-analysis published this year that does try to compare LTP vs supine positioning.
Reference: The lateral trauma position: what do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services. Scand J Trauma 19:45, 2011.
The Centers for Disease Control and Prevention (CDC) published a set of Guidelines for Field Triage two years ago. Click here to download them. They list 4 tiers of activation criteria to help prehospital providers triage patients appropriately to trauma centers.
Tier 1, which are physiologic criteria, and Tier 2 (anatomic criteria) are very accurate in predicting injury serious enough to require trauma team activation. Tier 3 contains mechanism criteria, and many centers who use these verbatim in their activation criteria end up with a fair amount of overtriage. Some centers even see a significant number of patients who meet Tier 3 criteria go home from the ED!
The Yale department of Emergency Medicine looked at intrusion into vehicle criteria (more than 12" near an occupant, more than 18" anywhere on the vehicle) to see if they are a valid predictor for admission or trauma center transport. It was a retrospective review of EMS transports to the Yale ED or to one satellite site.
Unfortunately, the number of vehicles that met intrusion criteria (48) was small compared to the number without significant intrusion (560). This makes the data a little less convincing than it may have been. The likelihood that intrusion would require trauma center admission (Positive Predictive Value) was only 26%. The likelihood that trauma center resources would be utilized (for issues like death, ICU stay, operation, spinal injury or intracranial hemorrhage) was only 13%. The authors recommend that the CDC guidelines be tweaked based on this data.
Bottom line: I think the numbers are far too small to convince the CDC to change their guidelines. But I would urge each trauma center that uses the intrusion criteria for activation to carefully study how many of those patients have minor injuries or go home from the emergency department. They may find that they can rely on other more accurate criteria and decrease their overtriage rate at the same time.
Reference: Motor vehicle intrusion alone does not predict trauma center admission or use of trauma center resources. Prehospital Emerg Care 15:203-207, 2011.
Today’s big headlines involve the recognition (finally) that law enforcement officers have risky jobs. But not just in the ways you might think. Sure, they frequently deal with criminals who have ill intent or deadly weapons. But some of the risks they face can be mitigated by simple actions.
Here are some factoids:
42% of police officers killed in auto crashes were not wearing seat belts
Overall seat belt compliance among law enforcement officers is about 50%, whereas the general public’s compliance is 86%
36% of officers killed are not wearing body armor
Unfortunately, a culture has developed among law enforcement (and prehospital / EMS professionals) that seat belts are not necessary (for them). The sad truth is that these professionals are at much higher risk for injury, especially in car crashes, because they must drive faster and in more stressful situations on a regular basis. And police officers (especially in the US) are more and more often confronted with firearms.
Why on earth would they not want this simple protection? Body armor is hot, unwieldy and uncomfortable, especially in warm weather climates. And police officers complain that seat belts complicate getting out of their vehicles, and can get snagged on their utility belts and uniforms.
A number of major police departments and police unions are now pushing for mandatory requirements for seat belts and body armor use at all times. There is now broad recognition that using these devices may cut fatalities in half. Agencies are beginning to check body armor at roll call, and random checks are sometimes performed on the streets by inspectors.
Unfortunately, we need to recognize this problem in EMS as well. And the culture there needs to change, so that protecting the trauma professionals becomes as important as helping the patients that they treat.
Reference: Characteristics of Law Enforcement Officers’ Fatalities in Motor Vehicle Crashes. US Dept of Transportation – National Highway Traffic Safety Administration, publication DOT HS 811 411.
Extreme Seat Belt Fail:
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