Good article about Pyng
Sternal Intraosseous Access in the Adult Patient
By Deede Vultaggio, Andy Swartzell, Al Kleveno, and Jason LeMoine
‘If only …” The phrase is repeated frequently by EMS providers, during classes, ride-alongs, and around the kitchen table at the station. “We had this really tough call last tour. If only …” We are always looking for ways to help EMTs and paramedics do their jobs more efficiently and effectively. It makes them happier in their jobs and serves patients better-our primary focus, after all.
Nothing is more frustrating than assessing a patient, determining an appropriate intervention, and being stymied in our attempts to administer medications because we weren’t able to establish an intravenous line because of the patient’s anatomical or situational problems. For a pediatric patient, we could quickly transition to an intraosseous (IO) administration of life-saving medications. Why can’t we use an IO on an adult? This article presents the option of sternal intraosseous infusion in seriously ill adults and discusses how Alameda County (CA) Fire Department has implemented a pilot study on this technique.
Historically Speaking
Intraosseous access has been around for years. It was recognized in the early 1920s as an alternative to intravenous access and was used frequently in the ’30s and ’40s. (Dublick, M & Holcomb, J; 2000) Like other trends in the practice of medicine, IO access has had its ups and downs in popularity. Our objective was to become familiar with current products on the market, their ease of use, their success rate, size, weight, and cost considerations.
A literature search provided multiple comprehensive comparison studies of various devices used in special operations and military applications. Practical testing in the private sector is either less frequent or not as well documented (Calkins, et. al., 2000).
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Intraosseous access is performed frequently during bone marrow biopsies as same-day outpatient procedures in both the pediatric and adult populations. According to standards set by PALS (Pediatric Advanced Life Support) and PEPP (Pediatric Education for Prehospital Professionals), IO infusions have been limited to patients aged 6 or younger, with the access site limited to the anterior tibia. The tibia has an advantage because of its large marrow space. However, as humans age, the cortex hardens; therefore, manual IO devices cannot be placed easily. Recently, however, new devices have been introduced that permit IO infusion in adults using the sternum.
Proposing the Study
There are as many variances in EMS protocols as there are medical directors and counties. In California, intraosseous infusion falls in the local optional scope of practice, meaning it requires authorization from the local EMS authority; for the authors, the Alameda County EMS Agency. Key steps were determining the device we wanted to use, preparing a comprehensive field study program, and obtaining the backing of the county’s medical director.
Our first priorities were effectiveness (i.e.: success rate) and ease of use. The Pyng F.A.S.T. 1TM is the only IO device we found that combines a high success rate, ease of use, simple training requirements, and cost effectiveness, meeting the criteria set for our research.
The F.A.S.T. 1 was found to be very simple to handle, from its concise and compact packaging to its application with a target patch and automatic depth control. The product also lived up to its name, taking 45 to 75 seconds to initiate. Because it is self-secured by the target patch and protective dome, it gives reassurance that it will not be easily dislodged or pulled apart during other procedures or while moving the patient. The device is small and when correctly placed is located high on the manubrium, where it will not interfere with CPR, C-spine precautions, cardiac pacing, defibrillation, or pleural decompression. Finally, the F.A.S.T. 1 is considered a central venous line, an important consideration for the treatment of critically ill trauma or medical patients, as the response to administered drugs is immediate.
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Once we determined our preferred device, our next step was to create a comprehensive and informative package to present to the county medical director. Several meetings ensued, complete with presentation of research, demonstration of product, and testimonials from Andy Swartzell, an experienced user. Discussions followed by more meetings resulted in an approved trial study. Key points of the study included
• 100 percent chart review;
• Identification of specific patient population eligible for sternal IO (age, weight, unconscious, in extremis);
• Written department protocol;
• QI tool, including notification of use;
• Monthly reporting to the county medical director; and
• Follow-up for patient outcome through receiving facilities.
In addition, local hospitals were notified by letter and were offered in-service training on the device, including specific instructions for removal.
Training Fire Crews
Fire department training followed a two-pronged approach. An initial introduction/familiarization lecture was accompanied by small group sessions that included hands-on training. Department staffing consists of crews of three or four people per apparatus with a mix of EMTs and at least one paramedic on each crew. It is imperative that the EMTs are trained to a high level of knowledge and competency so crews can function well as teams. Paramedics perform the ALS skills; however, it is crucial for the EMTs to see the “big picture,” anticipate the needs of paramedics, and have life-saving equipment ready for rapid implementation and intervention. Therefore, initial introduction of the F.A.S.T. 1 occurred during regular EMS task force training.
The second phase was intense training exclusively with paramedics in small groups and one-on-one settings. Refamiliarization included review, discussion, scenarios, and practice, with ample time for questions along with multiple applications of the device. This training occurred just before the field study started. Training materials supplied by Pyng were thorough and realistic, and the training devices held up well through multiple uses.
Putting It All Together
In the first 45 days, there were five uses of the sternal IO. All applications were successful, as set forth by predetermined standards, including proper site, placement, and flow. One example:
Patient was a 43-year-old male with a history of hypertension and chronic renal failure, dialysis dependent. Patient was found supine in bed, pulseless and apneic, with no bystander CPR. Family said patient had a decreasing level of consciousness, then became difficult to arouse but was still breathing. The wife stated that she called 911 when he stopped breathing.
Cardiac arrest was confirmed; the patient was moved to the floor, and CPR was initiated, including assisted ventilations via bag-valve-mask and manual compressions. ECG monitor showed asystole. The patient was successfully intubated, ventilated with 100 percent oxygen, and progressed to coarse V-fib. Patient was defibrillated at 200j, resulting in asystole. No IV access was appreciated so a sternal IO was established. A complicated “mega-code” followed with multiple drugs, shocks, and drips. After several minutes, there was return of spontaneous circulation, sinus tachycardia at 120 with a palpable radial pulse and spontaneous respirations.
Comments From the Field
Feedback was solicited from each paramedic who used the device. Reports indicated that the speed and simplicity of access with the sternal IO was a welcome surprise. Paramedics noted that response to medication was almost immediate. All enthusiastically stated that they would use the device again without hesitation. The feedback included tips to pass on, including a 10cc flush of the catheter with normal saline, followed by IV fluids augmented by pressure infuser bags at approximately 250 to 300 mm/hg. A reminder: some capillary bleeding may occur at the site; it is easily controlled with a sterile 4x4 dressing.
Looking Forward
This field study is still in its early stages, but results are positive. A great deal of discussion has ensued between the paramedics who have used the device and those who have not yet had the opportunity. Recurrency training for those wishing to review the skill is offered every Friday and by appointment.
We anticipate the field study to be completed with comprehensive results and statistics by year-end. For questions pertaining to this study, please contact Deede Vultaggio at deede.vultaggio@acgov.org or Al Kleveno at Alvin.Kleveno@acgov.org.
References
Alameda County EMS 2005 Field Manual
Calkins, MD, G Fitzgerald, TB Bentley, D Burris, (2000). “Intraosseous Infusion Devices: A comparison for potential use in special operations,” Journal of Trauma, Injury, Infection, and Critical Care, 48(6), 1068-1074.
Dublick, MA, JB Holcomb, (2000). “A Review of Intraosseous Vascular Access: Current status and military application,” Military Medicine, 165, 7:552.
Frascone, R., D Dries, T Gisch, K Kaye, J Jensen, (2001). “Obtaining Vascular Access: Is there a place for the sternal IO?” Air Medical Journal, 20:6. 20 - 22.
Pediatric Advanced Life Support Provider Manual. Dallas, : American Heart Association.
Pediatric Education for Prehospital Professionals (2000), Boston, Jones and Bartlett: American Academy of Pediatrics.
Deede Vultaggio, RN, BSN, is currently the EMS QI manager for Alameda County (CA) Fire Department. She has 18 years experience as a trauma nurse clinician at a Level 2 trauma center and has served as a flight nurse for CALSTAR. Vultaggio is involved in disaster and safety planning for local school districts. She also spends time teaching nurses, EMTs, and paramedics in programs such as TNCC (Trauma Nurse Core Course), and PEPP, among many others.
Andy Swartzell, RN, BSN, has been involved in EMS for 30 years as a paramedic, an EMS educator, a mobile intensive care nurse (MICN), and a flight nurse. He currently is a captain and EMS quality improvement coordinator with San Ramon Valley (CA) Fire Protection District.
Al Kleveno, EMT-P, is the EMS officer for Alameda County (CA) Fire Department. He has been a paramedic for 20 years. Klevenko is the program director for EMS supplies, a PEPP and PHTLS instructor, as well as the director for the EMT-1 program for Alameda County Fire Department.
Jason LeMoine, RN, EMT-P, is a firefighter for Alameda County (CA) Fire Department and a paramedic for the past two years. His nursing experience spans five years and includes CCU/NICU, surgical ICU, and the emergency department.
fireEMS May, 2005
Author(s) : Deede Vultaggio Andy Swartzell Al Kleveno Jason LeMoine
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