Accès veineux: Vision israélienne
Intravenous access in the prehospital settings: What can be learned from point-of-injury experience
Nadler R et Al. J Trauma Acute Care Surg. 2015;79: 221-226
La réalisation d'un abord vasculaire est un des gestes le plus souvent pratiqué. On rappelle qu'il s'agit là de pouvoir injecter certains médicaments (morphine, adrénaline, TXA, antibiotiques), d'initier un remplissage vasculaire raisonné voire d'administrer des dérives sanguins ou fractions coagulantes. Un document intéressant qui émane de l'armée israélienne fait le point sur cette pratique. Dans cette dernière (qui on le rappelle est assez spécifique compte tenu de la grande proximité des zones de combat et des structures hospitalières), il apparaît qu'il ne faille pas aller au delà de deux tentatives de pose de VVP au risque de retarder la prise en charge chirurgicale des blessés. Par ailleurs les taux de succès des médecins, combat medics et paramédics (pour nous nos infirmiers) soit superposable. Enfin la médiocre performance de l'accès intra-osseux doit interpeller.
Intravenous (IV) access has an essential role in the care provided for trauma patients, allowing for transfusion of blood products, fluids, and drugs. Decisions should be made regarding the necessity of IV access while considering cost-benefit of the procedure in terms of delayed evacuation times.
A retrospective review of all trauma patients in whom at least one attempt at IVaccess was performed were reviewed. Data were abstracted from the Israeli Defense Force Trauma Registry.
Of 7,476 patients, 1,082 patients who had at least one documented attempt at IV access between January 1997 and April 2013 were included in this study. Overall cumulative success rate at IV access was 82%. Success rates for IVaccess were 86%, 68%, 63%, 50%, 20% for the first, second, third, fourth, and fifth attempts, respectively. The first and second attempts accounted for 96% of the successful procedures. Mortality in patients for whom IV access was successful was 13%; mortality in patients for whom IV access was not successful was 35%.
The success rate of IV access declined with each subsequent attempt. There was minimal improvement of overall success rate seen after the second attempt. Our findings suggest that the inability to obtain peripheral venous access is associated with severe injuries. These finding support a policy of limiting the number of venous access attempts to two attempts, followed by a reevaluation of need for parenteral access. Improved training of combat medics and paramedics might marginally increase the success rates of IVaccess. Point-of-injury data, used for ongoing learning and research, form the ground for improving combat casualty care and thus help saving lives.