Your casualty has been shot three times in their left leg and one time in their right leg. They have absent radial pulses. You miss your IV attempt twice. How do you get your casualty fluid?

The most effective method for delivering fluids in this scenario is intraosseous (IO) access, specifically using the FAST 1 device. When a casualty has multiple gunshot wounds and is experiencing absent radial pulses, this indicates significant circulatory compromise, and rapid access to the vascular system is crucial.

In situations where peripheral IV attempts have failed, and especially when dealing with traumas such as gunshot wounds, IO access provides a reliable alternative. The bone marrow is highly vascular, allowing for immediate fluid resuscitation directly into the central circulation. This route is particularly useful in emergency situations where time is critical, as it can often be performed quickly and with minimal equipment.

Other options such as a subclavian IV or central line may be effective in accessing central venous return but require more time and skill, as well as a sterile environment, which may not be feasible in a pre-hospital setting with a severely injured patient. Peripheral IV is also not viable after failed attempts, which makes the IO route the most practical choice in this urgent context.