The Expanding Role of Ultrasound Vascular Access Procedures in Prehospital Emergency Medical Services Guglielmo Imbriaco, MSN, RN, CEN 1,2 Imbriaco G. The expanding role of ultrasound vascular access procedures in prehospital Emergency Medical Services. Prehosp Disaster Med. 2022;00(00):1–2. Dear Editor, In recent years, the use of ultrasound (US) guidance for vascular access procedures in the critical care setting has increased significantly, with proven benefits for both patients and clinicians, and it’s now considered the standard of care practice. 1 The undeniable clinical role of point-of-care US and the availability of compact, multi-probe portable US machines (dedicated to extended focused assessment with sonography for trauma/E-FAST or cardiac assessment) has led the way for further application to guide vascular accesses procedures by prehospital Emergency Medical Services (EMS). 2 Despite the concerns that US for vascular accesses could be seen as a time-consuming procedure, 3 it is beneficial to highlight its impor- tant clinical advantages, most notably the increased success rates, including patients with clinical signs of shock. The range of life-saving techniques presently available to EMS providers can strongly benefit from the addition of US guidance, either with central or peripheral venous or arterial cannulation. Ultrasound provides a safe and reliable tool for intravascular device insertion in a large “grey area” of patients, ranging from a simple blind-inserted peripheral access to a rapid intraosseous needle. With the rise in patients with difficult intravenous access, the use of US has been a game changer. 4 Radial artery access is gathering an increased attention in the EMS field. 5 The on-going COVID-19 pandemic brought out the opportunity for arterial punctures in the prehospital context, necessary for blood gas sampling and subsequent analysis through point-of-care testing systems, improving the quality of treatment provided to critical patients. 6 Arterial catheters offer additional value to provide effective continuous monitoring of unstable patients during ground or air transports from rural or remote areas as well as inter-hospital transports. A further application during medical emergencies is represented by femoral artery cath- eterization with sheath introducers; these intravascular devices and the use of US for a suc- cessful insertion are closely connected. A small-bore arterial sheath introducer (4Fr) can be inserted in the prehospital environment in hemorrhagic hypotensive patients, permitting effective pressure monitoring and timely evaluation to the clinical responses with fluid resus- citation or inotropic therapies. Once in the emergency department, the small-bore sheath introducer allows quick access for blood specimen collection and arterial blood gas analysis, and may be exchanged to a larger introducer through a guidewire, which may be used in hospital for invasive procedures (eg, splenic artery embolization in blunt trauma) or other endovascular procedures. Large bore sheath introducers (7-8Fr) are required for the femoral artery insertion of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheters; REBOA was introduced as a hemorrhage control technique in severe trauma and consists of an intra-aortic temporary balloon occlusion aimed at reducing bleeding. 7 The increased blood flow resulting from the REBOA has expanded its original indications for non-trau- matic cardiac arrest, obtaining better cerebral and coronary perfusion during cardiopulmo- nary resuscitation maneuvers. 8 The current application of US-guided vascular procedures by EMS providers may benefit the prehospital treatment of critically ill patients. In consideration of the 1. Centrale Operativa 118 Emilia Est (Prehospital Emergency Medical Dispatch Centre), Helicopter Emergency Medical Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy 2. Adjunct Professor, Critical Care Nursing, Bachelor in Nursing, Department of Medical and Surgical Sciences, School of Medicine and Surgery, University of Bologna, Bologna, Italy Correspondence: Guglielmo Imbrìaco, MSN, RN, CEN Centrale Operativa 118 Emilia Est (Emergency Medical Dispatch Centre) Helicopter Emergency Medical Service Maggiore Hospital Carlo Alberto Pizzardi Largo Nigrisoli 2, 40133 Bologna, Italy E-mail: guglielmo.imbriaco.work@gmail.com Conflicts of interest/funding: The author has no conflicts or financial interests related to this publication to disclose. No grants, funding (public or private), or financial support were received for this work. Keywords: arterial catheterization; Emergency Medical Services; prehospital emergency; REBOA; ultrasound guidance; vascular access Abbreviations: EMS: Emergency Medical Services REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta US: ultrasound Received: January 29, 2022 Revised: February 6, 2022 Accepted: February 12, 2022 doi:10.1017/S1049023X22000589 © The Author(s), 2022. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine. LETTER TO THE EDITOR April 2022 Prehospital and Disaster Medicine https://doi.org/10.1017/S1049023X22000589 Downloaded from https://www.cambridge.org/core, IP address: 52.73.204.196, on subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms.