Rapid intraosseous vascular access while wearing personal protective equipment

Abstract

<p><strong>Purpose:</strong> The ability to obtain rapid vascular access for fluid or medication administration is standard of care when working in emergency conditions. Hazardous material incidents require more sophisticated levels of personal protective equipment (PPE) that can interfere with fine motor skills needed for intravenous line placement. This study included participants representing a variety of clinical professions who could potentially face that challenge. Participants were tested for their ability to place intraosseous (IO) lines for quick antidote administration wearing various levels of PPE.</p> <p><strong>Design:</strong> This was an experimental study utilizing live anesthetized goats. Setting: The study was conducted in the lab animal research/experimental surgery center at a large university medical school facility in Texas.</p> <p><strong>Participants:</strong> A total of 18 volunteers were recruited, representing both prehospital and emergency department practice. The participants included six first responders (fire department paramedics and one physician with incident response training) and twelve first receivers (emergency department nurses, physicians, and physician assistants).</p> <p><strong>Methods:</strong> Approval from the Institutional Animal Care and Use Committee was obtained. Each subject completed a questionnaire prior to participation to quantify their previous experience with hazardous materials incidents, and use of the intraosseous device utilized in the study. The participants were designated to wear one of four levels of personal protective equipment in accordance with the US Environmental Protection Agency nomenclature. All operators were given brief (~10 minutes) instruction and an hour to practice with the intraosseous device. Operators were then randomized to a particular animal and to the order of level of personal protective equipment worn for each intraosseous attempt. Study subjects sequentially donned each level of PPE and placed intraosseous lines in one of four anatomical sites in twelve anesthetized goats. Placements were timed from the moment of touching equipment until a bolus injection of normal saline was delivered. Intraosseous placements were verified by aspiration of bone marrow and ability to flush the needle and the final insertion was additionally confirmed by fluoroscopy.</p> <p><strong>Results/Outcomes:</strong> First responders placed 100% of the intraosseous lines successfully. The median (interquartile range) times to completion (secs) were level A: 43.5 (23.0); B: 45.0 (29.0); C: 40.0 (15.0); D: 30.0 (17.0). First receivers placed IO lines successfully in 91% of the cases. Their median times to completion (secs) were level C: 42.0 (19.5); D: 37.0 (11.0). Differences in time to completion among PPE levels or between operator groups were statistically insignificant. Two placements resulted in extravasation. All infusions were completed successfully.</p> <p><strong>Implications:</strong> Placement of intraosseous lines for vascular access and early administration of antidotes can be accomplished rapidly and effectively while wearing PPE in a goat model. Similar success in humans in a clinical setting seems likely. Intraosseous access may make it possible to administer antidotes and other medications early in the resuscitation process of victims of hazardous materials incidents.</p>