MOVING THE NEEDLE ON TIME TO RESUSCITATION: AN EAST PROSPECTIVE MULTICENTER STUDY OF VASCULAR ACCESS IN HYPOTENSIVE INJURED PATIENTS USING TRAUMA VIDEO REVIEW
Authors: Dumas Ryan P. , Vella Michael A. , Maiga Amelia W. , Erickson Caroline R. , Dennis Brad M. , da Luz Luis T. , Pannell Dylan , Quigley Emily , Velopulos Catherine G. , Hendzlik Peter , Marinica Alexander , Bruce Nolan , Margolick Joseph , Butler Dale F. , Estroff Jordan , Zebley James A. , Alexander Ashley , Mitchell Sarah , Grossman Verner Heather M. , Truitt Michael , Berry Stepheny , Middlekauff Jennifer , Luce Siobhan , Leshikar David , Krowsoski Leandra , Bukur Marko , Polite Nathan M. , McMann Ashley H. , Staszak Ryan , Armen Scott B. , Horrigan Tiffany , Moore Forrest O. , Bjordahl Paul , Guido Jenny , Mathew Sarah , Diaz Bernardo F. , Mooney Jennifer , Hebeler Katherine , Holena Daniel N. 
Published: April 2023

Abstract

Introduction
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 IV (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 (TVR) was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤ 90 mmHg) 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
1,410 access attempts occurred in 581 patients with a median age of 40[27-59] years and an ISS of 22[10-34]. 932 PIV, 204 IO and 249 CVC were attempted. 70% 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[3.2-8.0] minutes. IO 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]sec; PIV 44[31-61]sec; CVC 171[105-298]sec) and was significantly different between IO vs. CVC (p < 0.001) and PIV vs. CVC (p < 0.001) but not PIV vs. IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes vs. 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)

Conclusions
IO 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. IO access should be considered a first line therapy in hypotensive trauma patients.

Level of evidence
Level II Therapeutic/Care Management