Prehospital intravenous access in children

doi:10.1016/S0196-0644(05)80054-X

Annals of Emergency Medicine

Volume 21, Issue 12, December 1992, Pages 1430-1434

https://doi.org/10.1016/S0196-0644(05)80054-X Get rights and content

Study objective:

To examine 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.

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.

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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Cited by (62)

Towards acute pediatric status epilepticus intervention teams: Do we need “Seizure Codes”?
2018, Seizure
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A study in adults analyzed components of delay in the pre-hospital setting and identified the most substantial sources of delay as delays calling paramedics, difficulty with administering a rectal medication, and inability of paramedics to administer a second-line ASM [76]. Studies have suggested that emergency personnel may have less experience treating children and therefore lack expertise [77], have more difficulty obtaining IV access in pediatric patients [78], and feel an increased level of stress when caring for children [79,80]. A recent study analyzing outcomes in pediatric SE patients treated by paramedics with or without completion of a pediatric simulation-based training course found pediatric trained paramedics were slightly more likely to administer a correct midazolam dose, though other outcomes did not differ between the two groups [81].
To identify areas of treatment delay and barriers to care in pediatric status epilepticus, review ongoing quality improvement initiatives, and provide suggestions for further innovations to improve and standardize these patient care processes.
Narrative review of current status epilepticus management algorithms, anti-seizure medication administration and outcomes associated with delays, and initiatives to improve time to treatment. Articles reviewing or reporting quality improvement initiatives were identified through a PubMed search with keywords “status epilepticus,” “quality improvement,” “guideline adherence,” and/or “protocol;” references of included articles were also reviewed.
Rapid initiation and escalation of status epilepticus treatment has been associated with shortened seizure duration and more favorable outcomes. Current evidence-based guidelines for management of status epilepticus propose medication algorithms with suggested times for each management step. However, time to antiseizure medication administration for pediatric status epilepticus remains delayed in both the pre- and in-hospital settings. Barriers to timely treatment include suboptimal preventive care, inaccurate seizure detection, infrequent or restricted use of home rescue medications by caregivers and pre-hospital emergency personnel, delayed summoning and arrival of emergency personnel, and use of inappropriately dosed medications. Ongoing quality improvement initiatives in the pre- and in-hospital settings targeting these barriers are reviewed.
Improved preventive care, seizure detection, and rescue medication education may advance pre-hospital management, and we propose the use of acute status epilepticus intervention teams to initiate and incorporate in-hospital interventions as time-sensitive “Seizure Code” emergencies.
Pediatric Vascular Access Peripheral IV Algorithm Success Rate
2018, Journal of Pediatric Nursing
Citation Excerpt :
Overall IV success may be based on the number of IV attempts and other factors. Among paramedics working in the field, the overall success rate was 68% in children's IV starts, and similar to our findings, success was higher among older children (Lillis & Jaffe, 1992). In our study, more attempts were made in the pre-algorithm group to achieve 92.1% success.
Determine if the pediatric peripheral vascular access algorithm (PPVAA) led to differences in first-attempt and overall peripheral intravenous (PIV) success, staff attempting PIV access per episode and overall attempts and first PIV attempt success by provider.
A two-cohort pre-/post-implementation comparative design involved pediatric nurses and patients. The PPVAA included four components: a patient comfort plan, PIV grading score, nurses' self-assessed IV access capability and nurse decision to stop-the-line. Two sample t-test or Wilcoxon rank sum test and Pearson's chi-square test were used to evaluate differences between groups and measures.
Healthcare providers (N = 96) attempted 721 PIV insertions (pre-PPVAA, n = 419 and post-PPVAA, n = 302). Of 78 nurse providers, mean (SD) age was 37.4 (11.0) years and 20.0% self-assessed PIV capability as expert. Of children, mean age was 8.3 (7.0) years. Post-PPVAA, first-attempt (p = 0.86) and overall (p = 0.21) success did not change, though fewer staff were needed per episode to initiate PIV; p = 0.017. Overall rate of success after one attempt in the post-PPVAA period compared to pre-PPVAA was reduced (p = 0.002), reflecting greater awareness to stop-the-line. Compared to pre-PPVAA, advanced practice nurses and non-clinician providers were more likely to achieve success on first attempt.
The PPVAA did not increase first-attempt or overall PIV success; however, it decreased overall IV attempts and the number of staff attempting access per episode.
The multi-component PPVAA provided a guide for nurses during PIV and assisted decision making to stop attempts in difficult cases.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 6. Paediatric life support.
2015, Resuscitation
Citation Excerpt :
Venous access can be difficult to establish during resuscitation of an infant or child. In critically ill children, whenever venous access is not readily attainable, intra-osseous access should be considered early, especially if the child is in cardiac arrest or decompensated circulatory failure.187–193 In any case, in critically ill children, if attempts at establishing intravenous (IV) access are unsuccessful after one minute, insert an intra-osseous (IO) needle instead.190,194
European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support
2010, Resuscitation
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In critically ill children, whenever venous access is not readily attainable intraosseous access should be considered early, especially if the child is in cardiac arrest or decompensated circulatory failure.155–157 In any case, in critically ill children, if attempts at establishing intravenous (IV) access are unsuccessful after 1 min, insert an intraosseous (IO) needle instead.155,158 Intraosseous access is a rapid, safe, and effective route to give drugs, fluids and blood products.159–168
European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary
2010, Resuscitation
Prehospital management of pediatric trauma
2010, Clinical Pediatric Emergency Medicine
Citation Excerpt :
A retrospective chart review of prehospital IV placement in pediatric patients, with subgroup analysis for trauma patients, showed a 57% success rate for IV placement in patients less than 6 years of age and 74% success rate in age 6 years or higher. Average time to IV placement in trauma patients was 14 minutes (range, 7-24 minutes) in age less than 6 years and 12 minutes (range, 1-43 minutes) in age more than 6 years.23 For some patients, decreasing on-scene time may be essential to survival, but for others, the benefit of initiating IV access may outweigh the risks.
A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.

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

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Original contributionPrehospital intravenous access in children

Study objective:

Design:

Setting:

Participants:

Measurements:

Main results:

Conclusion:

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Am J Emerg Med

Endotoxin shock in children

Resuscitation—Pediatric basic and advanced life support

Initial evaluation and management of the injured child

Original contribution
Prehospital intravenous access in children