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En route intraosseous access performed in the combat setting

Shelia Savell, PhD, RN, Alejandra G. Mora, BS, Crystal A. Perez, RN, BSN, Vikhyat S. Bebarta, MD, Joseph K. Maddry, MD


Objective: To describe and compare vascular access practices used by en route care providers during medical evacuation (MEDEVAC).

Design: This was a retrospective cohort study. Medical records of US military personnel injured in combat and transported by MEDEVAC teams were queried.

Patients: The subjects were transported by military en route care providers, in the combat theater during Operation Enduring Freedom (OEF) between January 2011 and March 2014. The authors reviewed 1,267 MEDEVAC records of US casualties and included 832 subjects that had vascular access attempts.

Main outcome measures: The outcome measures for this study were vascular access success rates, including intravenous (IV) and intraosseous (IO) attempts. Subjects were grouped by type of vascular access: None, peripheral intravenous (PIV), IO, and PIV + IO (combination of PIV and IO) and by vascular access (PIV or IO) success (No versus Yes). Survival rate, in-flight events, ventilator, intensive care and in hospital days, and 30-day outcomes were compared among groups.

Statistical analysis: The authors used chi-square or Fisher's exact tests to evaluate categorical variables. Analysis of variance (ANOVA) or Kruskal-Wallis tests were used for continuous variables.

Results: Vascular access was attempted in 832 (66 percent) of the 1,267 subjects transported by MEDEVAC during this study period. The majority (n = 758) of the access attempts were PIV of which 93 percent (706/758) were successful. In 74 subjects, IO was the only access attempted with an 85 percent (n = 63) success rate. The overall success rate with IO placement was 88 percent.

Conclusions: Intraosseous access has been used successfully in the combat setting and accounts for approximately 12 percent of vascular access in the MEDEVAC population the authors studied.


vascular access, intraosseous, prehospital, en route care, military medicine, war, combat

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Neumar RW, Otto CW, Link MS, et al.: Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122(S7): 29-67.

Committee on Trauma, American College of Surgeons. ATLS: Advanced Trauma Life Support Program for Doctors. 8th ed. Chicago: American College of Surgeons, 2008.

Fowler R, Gallagher JV, Isaacs SM, et al.: The role of intraosseous vascular access in the out-of-hospital environment (resource document to NAEMSP position statement). Prehosp Emerg Care. 2007; 11: 63-66.

Journal of Special Operations Medicine: TCCC Guidelines 150603. Available at Accessed March 8, 2016.

Owens BD, Kragh JF Jr, Wenke JC, et al.: Combat wounds in operation Iraqi freedom and operation enduring freedom. J Trauma. 2008; 64: 295-299.

Beecher HK: Preparation of battle casualties for surgery. Ann Surg. 1945; 121: 769-792.

US Army AKO, Army Knowledge Online: Critical Care Flight Paramedic Standard Medical Operating Guidelines (SMOG). Available at Accessed March 8, 2016.

Pozza M, Lunardi F, Pflipsen M: Emergency intraosseous access: A useful, lifesaving device used in Afghanistan. J Spec Oper Med. 2013; 13(1): 25-27.

Harcke HT, Crawley G, Ritter B, et al.: Feedback to the field: An assessment of sternal intraosseous (IO) infusion. J Spec Oper Med. 2011; 11(1): 23-26.

Worster A, Bledsoe RD, Cleve P, et al.: Reassessing the methods of medical record review studies in emergency medicine research. Ann Emerg Med. 2005; 45(4): 448-451.

Gilbert EH, Lowenstein SR, Koziol-McLain J, et al.: Chart reviews in emergency medicine research: Where are the methods? Ann Emerg Med. 1996; 27(3): 305-308.

Maddry JK, Savell S, Perez CA, et al.: Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes. J Trauma. 2016 (in press).

Anson JA: Vascular access in resuscitation is there a role for the intraosseous route? Anesthesiology. 2014; 120: 1015-1013.

Olaussen A, Williams B: Intraosseous access in the prehospital setting: Literature review. Prehosp Disaster Med. 2012; 27(5): 468-472.

Helm M, Haunstein B, Schlechtriemen T, et al.: EZ-IO® intraosseous device implementation in German Helicopter Emergency Medical Service. Resuscitation. 2015; 88: 43-47.

Leidel BA, Kirchhoff C, Bogner V, et al.: Evaluation of success rate and access time for an adult sternal intraosseous device deployed in the prehospital setting. Resuscitation. 2012; 83: 40-45.

Reades R, Studnek JR, Vandeventer S, et al.: Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: A randomized controlled trial. Ann Emerg Med. 2011; 58(6): 509-516.

Sunde GA, Heradstveit BE, Vikenes BH, et al.: Emergency intraosseous access in a helicopter emergency medical service: A retrospective study. Scand J Trauma Resusc Emerg Med. 2010; 18: 52.

Helm M, Haunstein B, Schlechtriemen T, et al.: EZ-IO® intraosseous device implementation in German Helicopter Emergency Medical Service. Resuscitation. 2015; 88: 43-47.

Lewis P, Wright C: Saving the critically injured trauma patient: A retrospective analysis of 1000 uses of intraosseous access. Emerg Med J. 2015; 32: 463-467.



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