Intra-Osseous Access in Difficult Vascular Access Cases

Not Applicable

Recruiting

Interventions: Device: Intraosseous venous access
Device: Peripheral venous access

Brief Summary: Thousands of peripheral venous accesses are inserted every day all over the world. Some of them, such as those inserted in emergency and / or in critical patients, are absolutely vital. In the particular context of prehospital care, the rate of failure of the first attempt to insert a peripheral venous access has been evaluated at 25%. Success rates of successive attempts were about 75%. Nevertheless, the final success rate is close to 100%.

Failure or delay in obtaining venous access can be life-threatening. Thus, alternatives to peripheral venous access have been proposed including intraosseous route recently made easier by the development of an automated puncture device (EZ-IO®), but still rarely used, especially on conscious patient.

Currently, the place of intraosseous venous access in critical patients is not determined.

Recruitment & Eligibility

Inclusion Criteria

Adult patient, in prehospital setting, without venous access and after failure of the first attempt to place a peripheral venous access by a senior operator (doctor or nurse) AND
Patient with hemodynamic failure defined as:
- systolic blood pressure (SBP) < 90 mm Hg (2 measures) or
- cardiac arrest or
Any situation requiring intubation

Exclusion Criteria

1- Age < 18 years

2- Venous access already available

3- Known contra-indications to intraosseous access (i.e. bilateral lesions):
Bone fracture
Skin infection
Osteoporosis
Osteomyelitis
Local burns
Recent failed intraosseous attempt
Prior surgery
Compartment syndrome
Every other local specific situations

4- Pregnancy woman

5- Patient with no national health or universal plan affiliation coverage

Arm && Interventions

Group	Intervention	Description
intraosseous venous access	Intraosseous venous access	intraosseous venous access
peripheral venous access	Peripheral venous access	Limiting use of intraosseous access (intraosseous access possible after 3 attempts of peripheral venous access)

Primary Outcome Measures

Name	Time	Method
To demonstrate that the early recourse to the intraosseous route, from the first failure, makes it possible to obtain more quickly the correction of the failure of critical patient managed in prehospital setting.	• In patients requiring endo-tracheal intubation: Achieve intubation, an average of 1 hour	• In patients requiring endo-tracheal intubation: time required to achieve intubation.

Secondary Outcome Measures

Name	Time	Method
To characterize the conditions for implementation of the procedure, depending on the strategy used.	In patients requiring endo-tracheal intubation: Achieve intubation, an average of 1 hour	Delays for administration of drugs/solutes
To evaluate morbidity depending on the strategy used.	Hours 72	Need to replace the venous access
To determine the length of stay in hospital	Days 28	Length of stay in hospital
To evaluate mortality depending on the strategy used.	Days 28	Death
To evaluate the patient's feedback, depending on the strategy used.	Immediately after the insertion of the catheter (opening of the perfusion) and on arrival at the hospital, In patients with hemodynamic failure: Reach a systolic blood pressure correction, an average of 1 hour	Evaluation of procedural pain on an analog visual scale, EVA, simple verbal scale, EVS or numerical scale, EN (from 0 to 100, the higher is the worse) In the case of patient with cardiac arrest, only the operator satisfaction will be assessed.
To evaluate the team's feedback, depending on the strategy used.	Immediately after the insertion of the catheter (opening of the perfusion) and on arrival at the hospital, In patients with hemodynamic failure: Reach a systolic blood pressure correction, an average of 1 hour	Operator satisfaction assessed (EVA, EVS or EN) after the placement of the catheter and on arrival at the hospital (from 0 to 100, the higher is the worse).