ORIGINAL CONTRIBUTION

intravascular access

Prehospital Intravenous Access in Children From the Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Buffalo, Buffalo, New York;* and Division of Emergency Medicine, Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri.t

Kathleen A Lillis, MD* David M Jaffe, MD*

Study objective: Toexamine the ability of a unified metropolitan paramedic system to provide IV access in children when indicated. Design: Retrospective, descriptive clinical study. Setting:

A large metropolitan area in Canada.

Participants: Five hundred thirteen children from birth through 18 years of age who were transported by paramedics.

Received for publication January 27, 1992. Revision received June 16, 1992. Accepted for publication June 29, 1992.

Measurements: Indications for IV access, rates of successful placement, and time to achieve access were determined. Criteria for IV line placement were developed and applied retrospectively,

Presented at the Ambulatory Pediatric Association Annual Meeting in New Orleans, April 1991.

Main results: Intravenous line attempts were made in 300 children (58%). Intravenous line placement was obtained in 253 (84% of the patients attempted). One hundred fifty-nine children met criteria for IV placement in the field. Six of these children were clinically dead and received no on-scene resuscitative efforts and Were excluded from data analysis. Of the remaining 153 children who met criteria, 122 (80%) had IV attempts made, and 104 (68%) had an IV line placed successfully. For children who met the criteria for IV placement, a significantly smaller proportion of children younger than 6 years had an IV line placed successfully (49%) compared with children 6 years or older (75%) (P< .005). Two subgroups of children who met criteria were examined: children with vital signs absent and trauma patients. For those who belonged to the subgroup with vital signs absent, a significantly smaller proportion of children younger than 6 years had an IV line placed successfully (43%) compared with children 6 years or older (92%) (P< .01) Eighty-four percent of patients who met criteria and who had one IV line successfully placed received only one IV line attempt, and 87% of patients who met criteria and who had two IV lines placed successfully received only two attempts. Conclusion: Although paramedics had an 84% success rate at establishing IV lines in children in the field, half the children younger than 6 years who required intravascular access did not receive an IV line in the prehospital setting. Multiple IV line attempts should be discouraged because additional attempts yield little benefit and may prolong transport times.

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ANNALS OFEM~RGENCYMEDICtNE 21:12 DECEMBER1992

IV ACCESS LiUis & Jaffe

[Lillis KA, Jaffe DM: Prehospital intravenous access in children.

AnnEmergMed December

1992;21:1430-1434.]

INTRODUCTION

Intravascular access provides an avenue for the administration of fluid and medication and is a fundamental procedure in the resuscitation of critically ill patients. 1-6 Obtaining IV access in a child can be a difficult and time-consuming procedure and is often attempted without success even u n d e r optimal conditions.S,7-9 I n a hospital setting, the median time to IV line placement in critically ill children has been reported as 7.87 and 10.0 minutes. 10 Paramedics are often faced with the task of establishing [V access under suboptimal conditions. Although paramedics are highly skilled in their work, several factors make field IV line placement in children difficult. Because less than 10% of paramedic calls are for children, 11 paramedics tend to have less experience establishing IV lines in children than in adults. The smaller veins and distribution of adipose tissue in children make both visualization and palpation of veins difficult. 12 The prehospital setting presents additional obstacles to success including poor lighting, little space, noise, and motion. The purpose of this study was to examine the ability of a unified metropolitan paramedic system to provide IV access when indicated. Specific objectives were to determine the proportion of children transported by paramedics who require IV access in the field; to determine the success rate of paramedics in establishing IV access in children; to evaluate the time required to establish IV access in children in the prehospital setting; and to determine the length of time spent in the prehospital setting without an IV line in those children who require IV access.

could not be obtained from the r u n sheets, an estimate was determined using the time of first paramedic contact with the patient and the time that the IV line was placed. Because there were no uniform criteria for IV hue placement in the field, we developed criteria and applied them retrospectively. These were cardiac arrest, shock, extensive b u r n s , major trauma, and intubation. Cardiac arrest was defined as an asystolic rhythm or no effective circulation. Shock was defined as the presence of three or more of the following: tachycardia or bradycardia, weak proximal pulses, absent peripheral pulses, hypotension, and altered level of consciousness. Extensive b u r n s were second-degree burns involving 15% or more of the body surface, b u r n s complicated by respiratory tract i n j u r y or fracture, or b u r n s involving critical areas such as the face, hands, feet, or perineum. The definition of major t r a u m a was a patient who sustained a significant amount of force and who had a depressed level of consciousness (Glasgow Coma Scale less than 15), a penetrating injury, or evidence of bony or abdominal tenderness. I n t u b a t i o n was defined as any patient who paramedics believed to require intubation regardless of whether attempts at intubation were successful. Two subgroups of children who met criteria were developed: children with vital signs absent and trauma patients. Trauma patients without vital signs were given the primary diagnosis of cardiac arrest and a secondary diagnosis of Table 1. Prehospital IV lines attempted and IV lines placed successfully

Total Criteria

MATERIALS

AND

METHODS

All metropolitan Toronto paramedic runs from J a n u a r y 1988 to December 1990 were screened to select transports of patients younger than 19 years. A detailed review of these r u n sheets was performed. Data collected included age, sex, vital signs, Glasgow Coma Score, paramedics' diagnoses, and significant physical findings. Times during the transport that were examined included time the crew was notified, time of arrival on scene, time of arrival to patient, time IV line was placed, time of first communication with the base hospital physician, time of departure from the scene, and time of arrival at the receiving hospital. All the times are recorded by the communication center and communicated to the paramedic at the completion of the r u n , with the exception of the time of arrival to the patient and the time of IV line placement. These two times are documented by the paramedic at the completion of the r u n based on his or her recollection of time. All IV line attempts were peripheral. Rate of successful IV placement and time to achieve IV access were determined. Because the exact length of time required to place an IV line

DECEMBER 1992 21:12 ANNALS OF EMERGENCY MEDICINE

Age < 6 years Age _>6 years

IV Line Attempts No. (%) P

IV Line Successfully Placed No. (%)* P

30 (70) NS 92 (84)

21 (49)t

Prehospital intravenous access in children.

To examine the ability of a unified metropolitan paramedic system to provide IV access in children when indicated...
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