Mind the GAHP: A novel protocol for improved vascular access in the hypotensive patient.

Background: Obtaining intravenous access in hypotensive patients is challenging and may critically delay resuscitation. The Graduated Vascular Access for Hypotensive Patient (GAHP) protocol leverages intraosseous fluid boluses to specifically dilate proximal veins. This study aims to evaluate the efficacy of GAHP in maximizing venous targets through early distal intraosseous access and a small fluid bolus. Methods: This was a prospective randomized cadaveric pilot study to evaluate extremity venous engorgement during intraosseous infusion. Cadavers (n = 23) had an intraosseous needle inserted into four sites: distal radius, proximal humerus, distal femur, and distal tibia. Intraosseous saline was rapidly infused, venous optimization was measured using real-time ultrasound. Primary outcome was maximum vessel circumference increase with intraosseous infusion. Secondary outcomes were: time to maximum circumference, and infusion volume required. Statistical analyses included Levene's test for equality of variances, Wilcoxon signed-rank test, and generalized estimating equation. Results: There was a significant mean increase of 1.03 cm (95% CI 0.86, 1.20), representing a difference of 102%. We found no significant difference in time to optimize vessel circumference across sites, but volume required significantly differed. Conclusion: GAHP quickly and effectively increased the circumference of anatomically adjacent veins. Anatomical sites did not differ on time to reach maximum enlargement of vessels following intraosseous infusion but did differ in terms of volume required to maximize vessel circumference. Further research is needed using live, hypotensive patients.

Bean Bag Projectile Causing Ocular Compartment Syndrome, Intracranial Hemorrhage, and Facial Fractures.

BACKGROUND: Bean bag rounds are a commonly used nonlethal projectile. Although they are generally reported to cause mild to moderate soft tissue injury, the potential for more serious injuries is only partially explored and may even be underappreciated. Injuries to the face, eyes, and head and their potential to inflict serious consequences, or even fatalities, are not well established. CASE REPORT: We present a case of severe head trauma caused by a bean bag round. Injuries included ocular compartment syndrome, intracranial hemorrhage, depressed skull fracture, and multiple facial fractures. Emergency department management of this patient required lateral canthotomy, intubation for airway protection, and management of suspected elevated intracranial pressure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although typically not regarded as serious, injuries caused by bean bag rounds have the potential to threaten life, limb, and vision. Emergency physicians should be aware of these possibilities, especially when the head is impacted, and should be prepared to perform critical actions and emergent procedures as needed. In addition, if not at a major trauma center, the emergency physician needs to be aware of the time-sensitive interventions required prior to transfer.