Sternal intraosseous devices are widely used in both civilian and military trauma when vascular access is difficult to establish. We discuss a rare complication of intraosseous needle insertion in two patients where the needle tip remained in the sternum after the device had been removed. Neither patient had evidence of any complication of the retained intraosseous needle tip after >6 years of follow-up.
- ACCIDENT & EMERGENCY MEDICINE
- INTENSIVE & CRITICAL CARE
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Sternal intraosseous (IO) needles are used in the military prehospital setting to establish vascular access when intravenous access is difficult to obtain.1 ,2 Several complications of sternal IO needles have been documented in the medical literature; these include extravasation of fluid, compartment syndrome, infection and rarely osteomyelitis.2 Two patients admitted to the Royal Centre for Defence Medicine (RCDM) for unrelated elective surgery were found to have retained IO needle tips in their sternum several years after their insertion. After over 6 years of follow-up, the retained needle tips have not caused any complications and we therefore suggest do not need to be removed.
A UK soldier on foot patrol was wounded by an improvised explosive device (IED) in 2009. He sustained multiple injuries including traumatic amputations. During prehospital care, a FAST1 IO sternal device (Pyng Medical) was inserted using the recommended technique to aid resuscitation. The patient was successfully resuscitated in the field, underwent initial surgical treatment at the Role 3 Medical Treatment Facility in Camp Bastion, Afghanistan and was subsequently evacuated to the UK Role 4 at the RCDM, Queen Elizabeth Hospital Birmingham. He was discharged to the Defence Medical Rehabilitation Centre (DMRC) Headley Court. It was noted during the index admission that part of the IO needle had remained in his sternum. The patient was informed of the retained needle tip at the time of his admission (Figure 1), and as there were no complications, there was no attempt to remove it. Seven years later, the patient has had no complications from the remaining needle tip.
A UK soldier was on foot patrol in Afghanistan in 2010 and was wounded by an IED. He sustained bilateral lower limb amputations. A FAST1 IO needle was inserted using a standard technique into the sternum during his prehospital management. Successful resuscitation was followed by damage control surgery at the Role 3 Hospital at Camp Bastion before evacuation to the Role 4 and onwards to DMRC. On review of his radiology during a routine visit for elective surgery in 2016, it was recognised that he had a retained needle tip (Figure 2). The patient was informed of the retained fragment, and confirmed that he had no adverse effects from the retained needle. It was decided that as there were no complications from the retained needle tip, the risk of surgery to remove this foreign body was likely to be greater than any benefit gained from removing it.
The FAST1 is a sternal IO device used when venous access is difficult to obtain due to severe haemorrhage, limb injuries or other access problems. It is inserted using a single-use delivery device which has an IO needle surrounded by several smaller needles; these ensure correct orientation of the device to allow accurate insertion of the device perpendicular to the sternum.3 IO needles may also be inserted into the humerus or the tibia, these devices being more commonly used in civilian practice in the emergency setting and in paediatric patients.
Short-term complications of IO needle insertions include difficulty aspirating bone marrow, slow injection of fluids and displacement after insertion. In the long run, they can cause osteomyelitis and in some cases compartment syndrome. These complications appear to be uncommon in clinical practice as compared with animal models.2 ,4 ,5 Specific documented complications of the FAST1 device include mediastinal injury, pneumothorax and injury to the great vessels,6 but the low risk of these complications is outweighed by the benefits of obtaining reliable access to the circulation for drug and fluid administration.2
The first-generation FAST1 IO came with a threaded rod which could be passed down the lumen of the plastic cannula and screwed into the metal IO needle tip to remove the IO part of the device. Some of these first-generation devices appeared prone to tip fracture and retention in the bone of the sternum. In the current version (the FASTX), a specific device is not required to remove the needle.3 Later versions of the FAST1 IO do not appear to be associated with tip fracture and retention.
There have been isolated case reports of retained FAST1 sternal IO needles after it was thought to have been removed; these patients had their retained IO needle removed surgically to prevent complications.7 ,8 A retrospective study showing a low rate of complications after almost a thousand IO insertions in military patients did not examine chest radiographs of the included patients, which suggests that IO needle tip retention may be more common than identified by this study and may be present in patients who are unaware of it.5
This is the first report describing long-term follow-up of patients with retained IO needles, neither of whom had any symptoms related to the sternum, but there remains a theoretical risk of late complications. We do not believe that these needle tips are a contraindication to MRI scanning, as they are small and unlikely to be significantly heated in the scanner, and are unlikely to move as they are implanted in the sternal bone.
Interestingly in patient two, the retained needle tip was either not recognised or dismissed as artefact on chest radiographs (Figure 2), but had a characteristic position and appearance both on chest radiography and more clearly on CT scans of the thorax (Figure 1). This differed to patient one who was informed of the retained needle early on. Civilian radiologists may not be aware of the appearance of IO needles as they are infrequently used in civilian trauma patients. There is a possibility they may be dismissed as weapon fragments or missed altogether. The second patient was not aware that there had been a foreign body in his sternum for 6 years until we informed him. Neither patients wanted operative management to remove the needle tip, but the Duty of Candour means that any similar patients should be informed of a complication of their treatment as soon as it is discovered.
A retained FAST1 IO needle tip is a recognised complication of sternal IO access. It can be diagnosed radiologically and if the patient has no symptoms attributable to it, can be left in situ. Clinicians should be able to recognise retained IO needle tips on radiographs, and should recognise that these can be present for many years without causing any complications.
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Contributors JK and AJ identified the patients. JK and JMH consented the patients. JMH wrote the first draft with assistance from AJ. JMH and AJ found and edited the imaging. JMH submitted and responded to review comments. JMH, AJ and JK edited final draft.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Army Medical Services.
Provenance and peer review Not commissioned; externally peer reviewed.
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