Tag Archives: iv access

The EMS Second IV In Trauma

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.

Trauma 20 Years Ago: Intraosseous Access

The pre-hospital concept of “scoop and run” was first popularized in the mid-1980’s. It came about because there was recognition that significant delays were occurring on scene. A big time sink was obtaining IV access. The failure rate for IV starts in the field was 10-40% and typical start times were in excess of 10 minutes!

As a result of “scoop and run”, the emphasis shifted to airway protection, c-spine stabilization and control of external hemorrhage. A quicker alternative to IV access was sought, and the idea of intraosseous access was revived.

IO access was first described in 1941, and was used in children due to the higher degree of difficulty in obtaining IV access in kids. It did not require visualization of the site and could be inserted in moving ambulances, including helicopters.

The authors of this paper looked at IO infusion using a sternal insertion site. This site was chosen due to the belief that only areas with red marrow were suitable. They found that delivery of fluids and drugs was virtually identical to IV. The authors did cite contraindications to using this device, including previous sternotomy, sternal fracture, osteoporosis, and congenital anomalies like pectus.

Ultimately, this paper revived interest in IO access for adults, which has now evolved to easy-to-insert tibial devices that are inserted with a power drill.

Reference: Evaluation of an Intraosseous Infusion Device for the Resuscitation of Hypovolemic Shock. Holcroft, Blaisdell et al. J Trauma 30(6): 652. 1990.

EZ IO device