Introduction

While discussions continue concerning the utility of obtaining prehospital vascular access, the skill remains a standard taught to EMS providers. Methods of access include peripheral and central intravenous (IV) catheterization and intraosseous (IO) access, depending on the local scope of practice and the qualifications of prehospital personnel. The medications and fluids administered through these various routes depend on local EMS protocol and the practices of the EMS medical director. Those specifics are beyond the scope of this chapter, but are discussed elsewhere in this text.

Benefits

Similar to its benefit in the emergency department (ED) or any other acute care setting, vascular access provides an avenue for medical intervention by the EMS provider. Early prehospital initiation of treatment for cardiac arrest, cardiac arrhythmia, and sepsis has been shown to be beneficial for patients [1–3]. For the more stable yet ill or distressed patient, the initiation of an IV or IO for symptomatic treatment of nausea, pain, or dehydration can help the continuum of care that will likely progress in the ED. Treatment of potentially reversible conditions like hypoglycemia and narcotic overdose in the prehospital setting can prevent deterioration of the patient’s condition and potentially negate the need for transport. Vascular access also facilitates advanced care such as rapid sequence intubation and the administration of vasopressors and thrombolytics.

Risks

Obtaining vascular access involves inherent risks to the provider, including blood exposure and needlestick injury. Whether it is attempted at the scene or in transit, the prehospital environment is often characterized by poor lighting, limited space, or movement in the rear of an ambulance. This offers less than ideal conditions in which to handle lancets, IV and IO needles, and other sharps. A combative and/or confused patient can add to the difficulty. Transmission of HIV, hepatitis B, and hepatitis C remains a constant threat to the EMS provider, with the risks of infection following needlestick injury estimated at 0.3%, 6–30%, and 1.8%, respectively [4]. Consistent use of universal precautions is imperative to reduce the likelihood of occupational exposures. Potential risks to the patient include bleeding, damage to adjacent structures, infection, and thrombosis and will be discussed later.

Establishing an IV is often part of EMS protocols. In many cases, protocols allow for EMS provider assessment and judgment regarding whether or not an IV is necessary. One study revealed that while over 50% of the patients who arrived at an ED via EMS had IVs in place, almost 80% of those IVs were not used in the prehospital setting. The tendency to err on the side of caution to avoid punitive measures from perceived undertreatment seemed to contribute to the discrepancy [5]. Another study similarly found that protocols seemed to drive the decision to start an IV as opposed to an actual need for administration of medicines or fluids [6]. Medical oversight is indicated to continually evaluate the appropriateness of “precautionary” IVs in the contexts of potential risks and costs to the system and to patients.

Several studies in the trauma setting have unveiled a lack of significant benefit regarding prehospital vascular access. The classic EMS mantra of “two large-bore IVs” for trauma patients has been muted by concern for increased on-scene times and delay of transport to definitive medical care. Nevertheless, two studies have shown high success rates when IVs were attempted in transit without delaying transport [7,8]. However, a literature review by the Eastern Association for the Surgery of Trauma resulted in a set of practice management guidelines that found no demonstrable benefit from prehospital IV placement or IV fluid administration for either penetrating or blunt injury patients [9]. Recent research in the field of trauma resuscitation suggests that routine administration of IV fluids may have no benefit and in fact can be harmful in the prehospital setting [10,11]. Another study endorsed “scoop and run” transport for EMS as it found that each prehospital procedure before ED thoracotomy led to a reduction in the odds of survival [12].