pain and anxiety in the pediatric patient associated with vascular access is often a difficult matter to address in the prehospital setting. The need for rapid vascular access in a critically ill child along varying transport times does not typically allow for some of the pharmacological options for relieving the pain of IV insertion that are available in the ED and hospital setting. Various commercially available creams, gels, and patches often require several minutes up to an hour of application time to be effective. Local infiltration of lidocaine with either a small‐gauge needle or needle‐free system such as the J‐Tip has quicker anesthetic delivery but requires a second, often psychologically traumatizing, needle puncture or startling noise caused by pressurized CO2. If the child is stable enough to consider the use of these pain‐reducing interventions, vascular access may potentially be deferred to arrival to the hospital. Medical oversight and training for pediatric patient care should focus on helping the EMS clinician distinguish the stable patient from the critically ill one who would benefit from early vascular access [28]. Additionally, for many EMS clinicians IV attempts for young children are infrequent and often difficult. Training may be needed to improve technical skills and confidence to increase success [29].
Ultrasound‐guided IV access
In ED care, ultrasound technology has become a useful tool to improve IV access success. Previously, patients who were unable to be cannulated by more traditional methods were often subject to more invasive procedures such as cutdowns or central lines, posing an increased level of risk. The growing widespread availability of ultrasound technology has found a role to augment the ability of clinicians to obtain IV access in a less‐invasive fashion. While a detailed instruction is beyond the scope of this text, ultrasound techniques can be used in a static fashion to identify the location of a suitable vein when one cannot be seen or palpated. The vein is then accessed by the usual techniques. Alternatively, a dynamic approach is often used, wherein the clinician uses ultrasound to visualize the needle tip and subsequently the catheter entering the vein, confirming placement. The materials and methods are largely similar to standard peripheral access techniques, with the exception of the need for an ultrasound machine, gel, and longer length catheters for accessing deeper veins.
Multiple studies have been performed analyzing the efficacy, speed, patency, and complications of ultrasound‐guided IV access. Across several inpatient and ED environments, ultrasound‐guided peripheral access shows trends toward being a comparable or preferable modality with regard to risk of failure, number of attempts, and procedure time [30]. There is clear demonstration of reduction of central line use when ultrasound is available to facilitate peripheral IV placement [31]. Success of ultrasound peripheral IV attempts was noninferior to the external jugular approach in those who failed traditional attempts [32].
With regard to prehospital use of this technology, barriers to implementation remain but are much less prominent than in previous years. Ultrasound machines remain expensive, and when accounting for rugged storage solutions, most devices require a nontrivial amount of physical space. Handheld ultrasound devices have been produced in recent years and may allow for feasibility studies of EMS‐initiated ultrasound‐facilitated IV access. As other applications for ultrasound are studied and implemented for prehospital use, the ability to gain vascular access may be an added benefit of the technology, even if not purchased for that primary purpose. As several other modalities are equivalent to if not faster than ultrasound‐guided peripheral IV placement, this technology may find a greater stronghold in alternative practice environments or in systems permissive of longer on‐scene times or for long‐distance or critical care transport (see Chapter 69).
Conclusion
Vascular access is a common procedure for EMS clinicians. In some cases it is to facilitate administration of needed medications or resuscitative fluids. In other cases, IVs are placed as a precautionary lifeline in case such measures are eventually needed. Many IVs are not used prior to arrival at an ED. It is important for EMS clinicians to possess the necessary skills and equipment to initiate vascular access under a myriad of conditions. Furthermore, this is an area that is appropriate for monitoring and evaluating from a quality improvement perspective, including both decision making and technical skill domains.
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