Intraosseous Access

Background: Vascular access is of paramount importance in the care of the critically ill patient. When central or peripheral intravenous access cannot be accomplished in a timely manner, intraosseous access and infusion is a rapid and safe alternative for the delivery of fluids, medications, and blood products. The resurgence of the use of intraosseous access in the 1980s led to the development of new methods and devices that facilitate insertion. Objectives: This article discusses general indications, contraindications, and complications of intraosseous access and infusion, focusing on new devices and their insertion. Discussion: Current research is focused on product innovation and improving drug delivery using intraosseous autoinjectors, finding new anatomic sites for placement, and expanding the use of different intraosseous devices to the adult population. Conclusions/Summary: New, improved intraosseous systems provide health care providers with choices beyond traditional manual intraosseous access for administering fluids.     

Intraosseous Emergency Access by Physicians Wearing Full Protective Gear

OBJECTIVES: To assess prospectively and randomly the feasibility, speed, and success rate of establishing an intraosseous access using the Bone Injection Gun (BIG) while wearing antichemical outfits. METHODS: Attempts to introduce intraosseous injection with or without a full protective gear (antichemical body suit, face mask, and butyl gloves) were performed using a turkey bone model. Time to proper placement was measured. RESULTS: The average time to successfully insert the BIG's needle while wearing a protective gear was 32 +/- 3 seconds compared with 22 +/- 2 seconds (p<0.05) without the outfit. Success rate was greater than or equal to 80%. When failure occurred, a second attempt always proved successful. CONCLUSIONS: The intraosseous insertion of the BIG's needle is rapid and easy but requires 50% more time when wearing protective gear than without it. Its use during emergent treatment of toxic mass casualty is of potential benefit and needs further investigation.     

Adult Intraosseous Access by Advanced EMTs: A Statewide Non-Inferiority Study

Objective: Intraosseous (IO) access is increasingly being used as an alternative to peripheral intravenous access, which is often difficult or impossible to establish in critically ill patients in the prehospital setting. Until recently, only Paramedics performed adult IO access. In 2014, Vermont Emergency Medical Services (EMS) expanded the Advanced Emergency Medical Technicians (AEMTs) scope of practice to include IO access in adult patients. This study compares successful IO access in adults performed by AEMTs compared to Paramedics in the prehospital setting. Methods: All Vermont EMS patient encounters between January 1, 2013 and November 30, 2015 were examined, and 543 adult patients with a documented IO access insertion attempt were identified. The proportion of successful IO insertions was compared between AEMTs and Paramedics using a Chi-Squared statistic and a non-inferiority test. Results: There was no significant difference in the percentage of successful IO access between AEMTs and Paramedics [95.2% and 95.6%, respectively; P = 0.84]. The confidence interval around this 0.4% difference (95% confidence interval = –4.2, 3.2) was within a pre-specified delta of ±10% indicating non-inferiority of AEMTs compared to Paramedics. Conclusions: This study's finding that successful IO access was not different among AEMTs and Paramedics lends evidence in support of expanding the scope of practice of AEMTs to include establishing IO access in adults.     

Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report

Background

Intraosseous access has been used increasingly with proven efficacy in emergent situations for adults when intravenous access could not be obtained.

Objective

Our aim was to demonstrate if tibial intraosseous (IO) is an effective route for iodinated contrast administration and pulmonary vasculature visualization.

Case Report

We report on an obtunded patient requiring a computed tomography angiogram to help with diagnosis and tibial IO was the only viable access appropriate to withstand the pressure of a computed tomography iodinated contrast load. Tibial IO access was used successfully for administration of iodinated contrast to evaluate for massive pulmonary embolism in an obtunded patient in extremis secondary to cardiovascular instability.

Conclusions

The pulmonary arteries were opacified and demonstrated a high-quality CT angiogram can be done via tibial IO device.     

The Role of Intraosseous Vascular Access in the Out-of-Hospital Environment (Resource Document to NAEMSP Position Statement)

Thousands of critically ill emergency patients are treated in the out-of-hospital setting in the United States every year. In many patients intravenous (IV) therapy cannot be initiated because of inadequate access to peripheral veins. In some cases, this lack of vascular access may limit benefit of medications because of late administration.[[]] Both speed andoverall success of vascular access are important when evaluating potential methodologies for their use in the out-of-hospital environment. Insertion of an IV cannula has been reported to require substantial time in the prehospital environment, with a recent study reporting an average successful intravenous line placement time of 4.4 ± 2.8 minutes.[[]] In critically ill pediatric patients, vascular access may present substantial difficulties to the provide.[[]] Intraosseous access may provide a significant time saving which may benefit many critically ill patients, both by decreasing the time to achieve access andby decreasing the time to administration of indicated medications.[[]] Achieving rapid administration of medications may facilitate the care of critically ill patients.[[]] Devices are now available that permit rapid, accurate access to the intraosseous space. Recent changes in the American Heart Association's resuscitation guidelines state that the intraosseous route should be the first alternative to difficult or delayed intravenous access.[[]] With these considerations, the role of intraosseous vascular access in the out-of-hospital environment should be reemphasized.     

Intraosseous infusion of phenytoin

In the critically ill child, administration of fluids and medications via the intraosseous route often proves life-saving. The authors describe the case of a child with status epilepticus in whom phenytoin was administered via the intraosseous route, and seizure resolution and therapeutic serum levels were achieved. Intraosseous drug administration should be reserved for the rare critically ill child in whom vascular access proves impossible.     

Intraosseous infusions in adults

Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. Twenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (13-gauge Kormed/Jamshidi®, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mL/min. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that I.O. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.     

Intraosseous infusion of muscle relaxants

This case report presents the resuscitation of a 6 1/2-month-old child with elevated intracranial pressure, seizure activity, and a presumptive diagnosis of shaken child syndrome. It is unique in the usage of an intraosseous infusion line for the administration of muscle relaxants and anesthetic agents to aid in an atraumatic intubation in this head-injured child. This is an original report of the usage of the intraosseous line for the administration of succinylcholine chloride, atracurium besylate, and thiopental sodium.     

Intraosseous infusions via the calcaneus

OBJECTIVES: To demonstrate that intraosseous infusions via the calcaneus could deliver fluids to systemic veins and that intraosseous infusions do not require bones with medullary cavities. To demonstrate that intraosseous infusions could be successful in adults. DESIGN: Ten adult cadavers were injected with 16 gauge intraosseous needles and infused with 10 ml of methyl green dye at a concentration of 10 mg/ml. MAIN OUTCOME MEASURES: Observation of methyl green dye in the great saphenous, medial malleolar and dorsal veins of the foot recorded by digital photography on injection and at 1 min post-injection. RESULTS: Immediate entry of methyl green dye into the superficial veins of the leg was seen in 14 out of the 20 legs trialled and delayed entry was noted in the two legs of another cadaver. No venous entry was seen in one cadaver and intraosseous access failed in one cadaver. CONCLUSIONS: Successful intraosseous infusions can be performed via the calcaneus. Intraosseous infusions can be successful in adult populations. While not a substitute for intraosseous infusions in other sites, the calcaneus provides an easily accessible site free of overlying vital structures.     

骨内腱鞘囊肿1例

患者,男,20岁。因右髋关节间歇性隐痛2年余,复发加重伴胀痛3个月入院。患者2年前无明显诱因出现右髋关节疼痛,为间歇性隐痛,无明显夜间疼痛加剧的表现。无畏寒、发热,无盗汗,无明显消瘦。3个月前上述症状加重,疼痛间隔时间变短,疼痛性质转为胀痛,在受压、撞击、屈髋时疼痛明显,     

Intraosseous infusions through non-styletted needles

This pilot study investigated the potential use of non-styletted needles for intraosseous infusion using a cadaver model. The results suggested that, in emergency situations, fluids may be successfully infused intraosseously using non-styletted needles.     

Emergent burn care

The estimated 32,600,000 fires that occur annually in the United States produce over 300,000 injuries and 7,500 deaths. Ten percent of hospitalized burn victims die as a direct result of the burn. Initial evaluation and management of the burn patient are critical. The history should include the burn source, time of injury, burn environment, and combustible products. The burn size is best estimated by the Lund and Browder chart, and the burn depth is determined by clinical criteria. Pulmonary involvement and circumferential thoracic or extremity burns require detection and aggressive treatment to maintain organ viability. Hospitalization is usually necessary for adults with burns larger than 10% of the total body surface area (TBSA) or children with burns larger than 5% of TBSA. Major burns, those of 25% or more of TBSA or of 10% or more of full thickness, should be considered for treatment at a burn center, as well as children or elderly victims with burns of greater than 10% TBSA. Lactated Ringer's solution, infused at 4 ml/kg/% TBSA, is generally advocated for initial fluid restoration. After the acute phase (48 hours), replacement of evaporative and hypermetabolic fluid loss is necessary. These losses may constitute 3 to 5 liters per day for a 40% to 70% TBSA burn. Blood transfusion is often required because of persistent loss of red blood cells (8% per day for about ten days). Many electrolyte abnormalities may occur in the first two weeks. Pulmonary injury commonly is lethal. Circumoral burns, oropharyngeal burns, and carbonaceous sputum are indicative of inhalation injury, but arterial blood gas determinations, fiberoptic bronchoscopy, and xenon lung scans are useful for confirming the diagnosis. Humidified oxygen, intubation, positive-pressure ventilation, and pulmonary toilet are the mainstays of therapy for inhalation injury. Wound care is initially directed at preservation of vital function by escharotomy, if restrictive eschar impairs ventilatory or circulatory function. Antibacterial agents may be applied to the burn, but invasive sepsis, defined as greater than 10(5) organisms per gram of tissue with invasion of subjacent viable tissue, requires systemic antibiotic therapy. Wound debridement is done by daily hydrotherapy, tangential excision, chemicals, primary excision, and grafting, tailoring the technique to the individual burn.(ABSTRACT TRUNCATED AT 400 WORDS)     

Intraosseous infusions: a usable technique

Intraosseous infusions were widely used in pediatric patients during the 1930s and 1940s. Recent reports have re-introduced this concept and confirmed its safety and ready accessability for fluid and drug administration. However, these reports have not addressed the difficulties encountered during insertion of the intraosseous needle. Spinal needles, standard metal intravenous (IV) needles, and bone marrow biopsy needles have been suggested for intraosseous infusion. These needles were tested for ease of insertion on a pediatric cadaver leg. The site for needle placement was also evaluated during the study. It was found that the 13-gauge Kormed/Jamshidi disposable bone marrow/aspiration needle was the easiest to insert and did not plug with bone or tissue during insertion. An area proximal to the medial malleolus was found to provide a stable, relatively flat, and easily penetrable location for needle placement. This method was successfully utilized in ten pediatric and five adult patients. Intraosseous needle placement is a safe, rapid method to gain access to the venous circulation. By utilizing these techniques, a stable, usable fluid line can be established in even the most dehydrated pediatric patients.