Journal Article Synopsis: Vascular Access during Out-of-Hospital Cardiac Arrest

Summary of “Journal Article Synopsis: Intraosseous Versus Intravenous Vascular Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial,” Reades, Rosalyn, MD; Studnek, Jonathan R., PhD, NREMT-P; Vandeventer, Steven, EMT-P; Garret, John, MD.  Annals of Emergency Medicine. 2011 Aug 17. [Epub ahead of print]

What is already known on this topic:
Intraosseous vascular access was originally used mainly in children.  However, it has recently been shown that this method is also a rapid and effective way to obtain vascular access in the adult population, especially when a peripheral intravenous line fails.  Therefore, this technique is used commonly in out-of-hospital settings when rapid vascular access is needed during cardiac arrest.  Emergency Medical Services (EMS) protocols in the US list sternal, humeral, and tibial locations as available sites for intraosseous vascular access.

What question this study addressed:
The humeral and tibial locations are better sites during cardiac arrest due to constant chest compressions.  However, data regarding the effectiveness of the humeral site versus the tibial site are limited.  This study assessed the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous routes during out-of hospital cardiac arrest.

What was the study design:
This study was a prospective, nonblinded, triple-arm, randomized control trial of 182 adult patients over 18 years of age experiencing a non-traumatic out-of-hospital cardiac arrest in which resuscitation was initiated.  Patients were randomized to one of 3 vascular access routes: tibial intraosseous, humeral intraosseous, or peripheral intravenous.  Paramedics received extensive training in each method.  The outcome measure was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein with normal fluid flow.  If a needle dislodged, it was considered a failure.

What this study adds to our knowledge:
Tibial intraosseous vascular access was determined to be the optimal method with regards to highest success rate and fastest time to access.  However, peripheral intravenous access was associated with a higher volume of infused fluid.

How this is relevant to clinical practice:
Tibial intraosseous vascular access is beneficial for patients in who are in cardiac arrest or unconscious and who are unlikely to need large-volume fluid resuscitation.  Its location is more removed from the primary site of resuscitation efforts, and is generally not beneath large amounts of soft tissue.

Other considerations:
The cost of intraosseous vascular access is much greater than the cost of peripheral intravenous vascular access.  Further studies should be conducted to determine the cost effectiveness of tibial intraosseous over peripheral intravenous access.

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Book Review: Minor Emergencies – Splinters to Fractures

This review is for the book Minor Emergencies – Splinters to Fractures, 2nd edition by Philip Buttaravoli, MD, which can be purchased here. The reviewer has received no financial renumeration for this review.

This is a book that I purchased because I felt that many of the everyday clinical problems that I might encounter in the ED (or just walking around in a hazardous world) had not been formally taught in the curriculum, and had not been encountered by myself yet in my outpatient rotations. We learn a lot about carcinoid tumors, pheochromocytomas, the histology of thyroid cancers, and enzymatic pathways, but not very much about how to handle poison ivy exposure, finger dislocations, torn earlobes, or foreign body removal- despite the fact that we are very likely to encounter these problems at some point in our career. The author makes the point in the preface that the assumption is that “if you haven’t completed your training, you can’t do any harm if the conditions to which you are assigned responsibility aren’t very serious”; however, “care still needs to be appropriate so that the condition won’t deteriorate into a true threat to life or limb”. I fully agree with the author that minor emergencies, as much as any other medical issue, deserve to be treated seriously and with an eye towards providing evidence-based, cost-effective, and efficacious evaluation and treatment.

To this end, I believe that this book definitely fulfilled those goals. The text of the book, not including the index, is 807 pages long and divided into 184 chapter (and 8 appendices). Each chapter ranges from about 2 to 6 pages in length. The chapters are organized in sections, ranging from Neurologic and Psychatric Emergencies to Musculoskeletal Emergencies. Each chapter follows a uniform format with an initial discussion of the presentation of the complaint, followed by recommendations on what to do, and recommendations on what not to do, and concluding with a general discussion  of the topic. There are numerous references provided in case you want to explore a topic more deeply. The book is in full color and there are both photographs and clearly done illustrations. Notably, there are no tables in the book, which I take as a refreshing change from the usual medical textbook, which I feel often substitutes tables for clear and concise writing.

Strengths of the book included brevity of the writing, excellent illustrations, comprehensiveness, and attention to practical detail. The only disadvantage that I can see is that the book cover promises that there is handheld software included with the book; however, I contacted the publisher (Elsevier), and they informed me that the service used to run the software has been discontinued.

Overall score (out of 5 stars):

Book Review: Wounds and Lacerations – Emergency Care and Closure

This review is for the book Wounds and Lacerations: Emergency Care and Closure, 3rd edition by Alexander T. Trott, MD, which can be purchased here. The reviewer has received no financial renumeration for this review.

This is a book which I picked up for my outpatient surgery clerkship in preparation for both that rotation and my upcoming EM rotations. I had hoped to learn from a reputable source the very basics involved in wound repair, which I felt were somewhat lacking in the general curriculum, as well as some advanced techniques. I was looking for a book that was evidenced-based, rather than tradition-based, and covered a fair amount of ground while not being overly arduous to get through in a 3 week period.

Overall, I feel that this book fulfilled those goals, and generally quite well. The text of the book, not including the index, is 316 pages long and divided into 22 chapters. It begins with an overview of emergency wound care and assessment, and gradually builds up in a logical succession in a sequence of how you would close a wound in the ED, beginning with assessment, followed by anesthesia, then cleansing, then choosing suture material and instruments, then techniques both for repairing simple and complex wounds. The book then transitions to special situations, such as facial or hand wounds, bites, burns, foreign body removal, etc. The book makes sure to cover even the “simple” but essential issues involved in wound care which are probably not ever going to be formally taught. For example, in the chapter on wound cleansing, there are subsections dedicated to what sort of solutions to use, how to irrigate properly and with the correct instrument, positioning the patient, and so on. Likewise, there is a 28-page chapter on wound dressing and bandaging with copious illustration.

Strengths of the book included brevity of the writing and many illustrations (tri-color only, unfortunately) and attention to all portions of wound care in a primary survey of the subject. Weaknesses included the fact that the text and the illustrations were sometimes a bit awkwardly out of sync, which might be confusing if attention was not paid to which figure number in the text matched up to which figure (in other words, the figures on one page often were referenced to on the previous page, rather than the current page). The subsections could also sometimes occasionally be a little too brief, although I am hesitant to consider this a significant weakness, since it ensured that the most essentially information didn’t get lost in text (as I feel often happens in textbooks).

Overall score (out of 5 stars):