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Introduction Mechanism Assessment Management The FAST1 intraosseous cannula Conclusion
The FAST1 I/0 is a relatively recent addition to the vascular access inventory. It is designed exclusively for use in the manubrium and has advantages of rapid, consistently accurate placement, reasonable flow rates and low risk of dislodgement thanks to its low profile. The main disadvantages are cost (£95 - £130) and the requirement for a short training course (30 minutes) which can be provided by the device representative or by suitably experienced colleagues with access to the training equipment. The device is not MRI compatible and is contraindicated in sternal fractures. Because it is sited in the manubrium it is safe to use during CPR.
The accident involved an adult driver of a left-hand drive lorry colliding with the abutment of a flyover. The lorry had left the road, travelling up and along the embankment, before impacting the wall almost head-on, at speed, remaining upright throughout.
On our arrival, the patient was still trapped by his legs and receiving care from on-scene crews. He was responding only to pain and had severe facial injuries.
Primary survey revealed a partial airway obstruction with some intra-airway bleeding. C-spine care required manual in-line stabilisation with the patient leant forward to maintain airway patency. Respiratory examination found tachypnoea but normal chest signs. Oxygen was being provided. Cardiovascular examination revealed a good radial pulse, HR 75 and no obvious signs of haemorrhage although capillary refill was prolonged, possibly due to cold. IV access had been obtained by land crews on scene. Of greatest concern, his GCS was 6/15 (E-1, V-1, M-4) with probable rhinorheoa. There were no other obvious significant injuries.
The kinetics of injury, obvious facial injury with airway haemorrhage and low GCS warranted urgent, definitive airway control, supplementary oxygen and optimum management of his intracranial injuries. A RSI and immediate transfer to a hospital with neurosurgical facilites was required. The extraction was consequently expedited with the firecrew using a hydraulic ram to perform a dashboard roll and the casualty extricated in the right decubitus position (for airway preservation) onto a longboard. C-spine control was via rigid collar and MILS.
The patient was placed on an ambulance stretcher, still in the right lateral position, and prepared for RSI with pre-oxygenation, essential monitoring and having suction available. Unfortunately IV access had been lost during extrication and peripheral veins were shut down making IV access difficult. We therefore resorted to the FAST1 I/O cannula.
The FAST1 Intraosseous Cannula
The FAST1 I/O is presented as a comprehensive kit including stick-on siting aid, preloaded cannula delivery handset, cannula removal tool, luer lock connection tubing and an adhesive transparent dome to protect the insertion site. The siting aid is a circular adhesive patch with a defect to match the sternal notch and two short limbs which overlie the head of each clavicle. When correctly placed, a small membrane approximately 1cm in diameter corresponds to the insertion site in the manubrium. (See demonstration photo)
Despite the displaced surface anatomy created by the lateral position, the landmarks were clearly palpable and the sticker was placed with relative ease. To insert the FAST, the device is introduced perpendicular to the manubrium. This is ensured by the 10 guide needles surrounding the I/O which will only release the cannulation mechanism when the pressure in all 10 needles is equal. Secondly, the pressure on all 10 needles has to be above a minimum level to ensure that the force being applied when the release mechanism activates is sufficient to drive the cannula through the cortical bone into the marrow. Success rates depend on experience and range from 85 to high 90’s percent.
Once the I/O cannula was placed and connected, the line was flushed to ensure patency and the patient was given Etomidate 16mg. Cricoid pressure was applied and the patient was turned supine. At this point, suxamethonium 100mg was administered and flushed through - muscle fasciculations commenced and receded within thirty seconds indicating that manubrial intraosseous cannulation provides good vascular access on a par with a good peripheral line. Subsequent fluid flows proved reasonable even without pressure bags or syringing.
Post intubation the casualty was conveyed to an appropriate tertiary centre using the air ambulance.
The FAST I/O cannula is simple to use after a brief training course, quick to site, secure and effective for administration of IV drugs – including those requiring rapid central delivery – and maintenance fluids. Unfortunately it is probably too expensive for routine use but does make a valuable alternative in certain scenarios.
Conflicting interests - none.