What is the next step for a provider to secure vascular access in a deteriorating traumatic patient after two failed attempts at peripheral intravenous (IV) access?

Immediate Intraosseous Access After Two Failed Peripheral IV Attempts

After two failed attempts at peripheral IV access in a deteriorating trauma patient, the provider should immediately place an intraosseous (IO) needle (Answer B). This is the fastest, most reliable method to establish vascular access in this critical situation and is explicitly recommended by multiple guidelines for this exact scenario.

Rationale for IO Access

IO access is the definitive next step when peripheral access fails in a deteriorating patient. The evidence strongly supports this approach:

• Guidelines explicitly state that in the event of peripheral IV failure, intraosseous or surgical venous access may be required 1
• IO access can be established in approximately 2-3 minutes, compared to 10 minutes for central venous catheterization 2
• Success rates for IO access on first attempt are 90%, compared to only 60% for central venous catheters in emergency situations 2
• IO access is specifically recommended as a Class I indication (highest level) for cardiac arrest and difficult vascular access scenarios 1

Why Not the Other Options

Option A (Activate Code): Incorrect

• Activating a code is for cardiac arrest situations, not for vascular access failure 1
• The patient is deteriorating but not necessarily in cardiac arrest
• This wastes critical time when immediate vascular access is needed

Option C (Arterial Line): Incorrect

• Arterial lines are for hemodynamic monitoring, not for resuscitation or medication administration 1
• Cannot be used to administer resuscitation fluids, blood products, or most medications
• Does not solve the fundamental problem of needing venous access for resuscitation

Option D (Call Another Provider): Incorrect

• Time-to-vascular-access is the critical determinant of mortality in deteriorating trauma patients 1
• Waiting for another provider delays definitive care
• IO access is faster and more successful than even experienced providers attempting central access 2

Clinical Implementation

The IO route allows administration of all critical resuscitation interventions:

• All intravenous medications can be given IO, including vasopressors, ACLS drugs, blood products, and crystalloids 1, 3
• Onset of action and drug levels are comparable to IV administration 1
• Flow rates up to 125 mL/min can be achieved, adequate for resuscitation 4

Preferred IO insertion sites in adults:

• Proximal tibia (2 cm distal to tibial tuberosity, 1 cm medial) 1
• Proximal humerus 4
• Sternum (using specialized devices like FAST-1) 5, 4

Critical Timing Considerations

Every minute of delay in vascular access increases mortality:

• Mortality increases by 1% for every 3 minutes of delay in achieving vascular access 1
• IO access takes a median of 3 minutes from decision to first infusion 6
• Central venous access takes nearly 10 minutes and has lower first-attempt success rates 2

Common Pitfalls to Avoid

• Do not attempt more than 2 peripheral IV attempts in a deteriorating patient - this wastes precious time 1
• Do not default to central venous access as the next step - it is slower and less successful than IO in emergency situations 2
• Remove IO access within 24 hours or as soon as definitive IV/central access is obtained 4, 6
• Follow each medication with saline flush to promote entry into central circulation 1

Complications

IO access has minimal complications:

• Extravasation is the most common complication, occurring in approximately 7% of cases 6
• Major complications (osteomyelitis, compartment syndrome, fracture) occur in <1% of cases 1, 3
• Minor complications (device failure) occur in approximately 1.4% of cases 3

Once IO access is established, continue resuscitation while simultaneously working to obtain more definitive central or large-bore peripheral access 6. The IO serves as a critical bridge that prevents delays in life-saving interventions while more permanent access is secured.