Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

Introduction

Current guidelines recommend intraosseous (IO) vascular access in adults if peripheral venous access is unavailable. Most available data derive from children, animal models, cadaver studies or the prehospital setting. Therefore we compared two different IO access devices in adults under resuscitation in the hospital setting.

Patients and methods

This prospective, randomized clinical study compared two different IO access devices in adults (≥18 years of age) under trauma or medical resuscitation admitted to our emergency department with impossible peripheral venous access. Each adult was randomized to either spring-loaded BIG Bone Injection Gun or battery-powered EZ-IO. Outcome measures included success rates on first attempt, procedure times and complications.

Results

Forty consecutive adults under resuscitation were enrolled. Twenty patients received the BIG, another twenty patients the EZ-IO. Over all success rate on first attempt was 85% and mean procedure time 2.0 min ± 0.9. Comparing the two devices, success rate on first attempt was 80% for the BIG versus 90% for the EZ-IO and mean procedure time was 2.2 min ± 1.0 for the BIG versus 1.8 min ± 0.9 for the EZ-IO. The differences between both IO devices were not statistically significant. No other relevant complications like infection, extravasation or bleeding were observed.

Conclusions

IO vascular access was a reliable and safe method to gain rapid vascular access for in-hospital adult emergency patients under resuscitation. Further studies are necessary regarding comparative effectiveness of different IO devices.     

Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment

Introduction

Rapid intravascular access is a prerequisite component of emergency care and resuscitation. Peripheral intravenous (IV) access is the first-choice for most of the medical or trauma patients, but may be delayed in emergency conditions because of various difficulties. Elsewhere, intraosseous (IO) access may now be easily performed with a new semi-automatic battery-powered IO-insertion device (EZ-IO^®). The aim of this study was to compare the overall time to establish IO infusion with the EZ-IO^® device and the equivalent time for peripheral IV infusion, performed by emergency personnel in standard (No-CBRN) and in chemical, biological, radiological, and nuclear (CBRN) protective equipment.

Methods

Nine nurses and 16 physicians randomly performed 4 procedures on a training manikin: IV and IO access under No-CBRN conditions and IV and IO under CBRN conditions. The time for each infusion attempt included all the steps essential for a simulated safe clinical use of infusion.

Results

Under No-CBRN conditions, the time to establish IO infusion was shorter than the equivalent IV time (50 ± 9 vs 70 ± 30 s). Similarly, under CBRN conditions, the time for IO infusion was shorter than for IV infusion (65 ± 17 vs 104 ± 30 s). The mean time saved by IO infusion over IV infusion was respectively 20 ± 24 s (P < 0.001) and 39 ± 20 s (P < 0.001) under No-CBRN and CBRN conditions.

Conclusion

The time to establish IO infusion was significantly shorter than that for peripheral IV infusion, under both No-CBRN and CBRN conditions. Further clinical studies are required to confirm that IO access would effectively save time over IV access in real pre-hospital emergency settings.     

MRI findings of an intermuscular lipoma in a 2-year-old

We report the MRI findings of a large deep intermuscular lipoma in a 2-year-old child with a painless palpable shoulder mass, and its differentiation from liposarcoma and other soft-tissue masses. To our knowledge, the imaging features of deep lipomas in children have not been reported.     

Musculoskeletal CPD revision: Cases from the New Zealand Bone & Soft Tissue Tumour Registry

This case report has been selected from the New Zealand Bone & Soft Tissue Tumour Registry to highlight some key concepts and findings in musculoskeletal imaging with radiological‐pathological correlation. The case is presented in a question and answer format, with clinical information and selected images in one section, followed by the diagnosis, discussion and teaching points.     

Comparison of two mechanical intraosseous infusion devices: A pilot, randomized crossover trial

Introduction

Administration of medications via the intraosseous (IO) route has proven to be a lifesaving procedure in critically ill or injured children. Two mechanical IO infusion devices have been approved for use in children, the spring-loaded IO infusion device (Bone Injection Gun, BIG) and the battery-powered IO infusion drill (EZ-IO). The objective of this pilot study was to compare the success rates for insertion and the ease-of-use of the two devices.

Patients and methods

A randomized crossover study was conducted in a local paramedic training course with 29 paramedic students participating. Participants watched two videos describing the use of the two devices, followed by a demonstration on how to use each device on a turkey bone model. Then subjects were divided into two study groups: BIG-first or EZ-IO-first. Each participant performed one insertion attempt with each device independently. All attempts were filmed by a video camera. Successful placement was defined as the visualization of fluid flow from the marrow cavity. Following the study procedure, participants completed a two-item questionnaire recording their ranking of the ease-of-use of each device and their “first choice device”.

Results

Participants had a significantly higher one-attempt success rate with the EZ-IO than with the BIG (28/29 vs 19/29, p = 0.016), and selected the EZ-IO as their first choice (20/29). Participants of the EZ-IO-first group assessed the EZ-IO as easier to use than the BIG (p = 0.0039). The subjects of the BIG-first group found no difference in the ease-of-use between the two devices (p = 0.32).

Conclusions

As tested by paramedic students on a turkey bone model, the EZ-IO demonstrated higher success rates than the BIG and was the preferred device. Future studies are planned to determine which of the two devices is more appropriate for obtaining IO access in the setting of paediatric emergencies.     

Trigger finger at the wrist caused by an intramuscular lipoma within the carpal tunnel: A case report

BACKGROUNDTrigger finger at the wrist, which occurs with finger movement, is an uncommon presentation. Few reports describing cases of trigger finger at the wrist have been published. Thus, we present a case of an intramuscular lipoma arising from an anomalous flexor digitorum muscle belly in a 48-year-old female patient causing painful finger triggering at the wrist and carpal tunnel syndrome (CTS).CASE SUMMARYA 48-year-old woman with complaints of a catching sensation during wrist motion and a progressive tingling sensation on the palmar aspect of the right hand for approximately 2 years was referred to our hospital. Triggering of the index to middle finger was evident with a palpable and audible clunk over the carpal tunnel during passive motion. Tinel’s sign was positive over the carpal tunnel of the right wrist with a positive Phalen’s test. Nerve conduction studies of the median nerve demonstrated a right CTS. Ultrasound examination revealed a 2.5 cm × 2.0 cm subcutaneous hyperechoic mass with no obvious blood flow at the wrist of the right arm. Surgical excision of the tumor and muscle mass led to a resolution of the patient’s symptoms, and any triggering or discomfort disappeared. The patient has had no evidence of recurrence at more than 1 year of follow-up.CONCLUSIONTriggering of the fingers at the wrist is rare. It must be noted that there are many possible causes and types of triggering or clicking around the wrist. Accurate diagnosis is mandatory to avoid inaccurate treatment of patients with trigger wrist. During the diagnosis and treatment of CTS, attention should be paid to the variation of tendon tissue in the carpal tunnel, to avoid only focusing on the release of transverse carpal ligament and ignoring the removal of anomalous muscle belly.     

Magnetic resonance imaging of lipoma and atypical lipomatous tumour/well-differentiated liposarcoma: observer performance using T1-weighted and fluid-sensitive MRI

The aim of this study was to evaluate observer performance using T1-weighted spin-echo and fluid-sensitive MRI sequences in distinguishing between lipoma and atypical lipomatous tumour/well-differentiated liposarcoma (ALT/WDL). Magnetic resonance images of 51 patients with benign lipoma and ALT/WDL of the musculoskeletal system were reviewed. There were 33 benign lipomas and 18 ALT/WDL. The character of septa and nodularity of the fatty tumours on T1-weighted spin-echo sequences and the presence of high signal on fluid-sensitive sequences were assessed. Two independent observers took part. Observer agreement was measured. The two observers achieved sensitivities of 100 and 94% for T1-weighted images and 100% each for fluid-sensitive sequences. Specificities were 76 and 64% for T1-weighted and 70 and 73% for fluid-sensitive images. Observer agreement was very good (kappa 0.87 for T1-weighted and 0.88 for fluid-sensitive images). In distinguishing lipoma from ALT/WDL, observer performance was comparable using T1-weighted and fluid-sensitive MR sequences. High sensitivity and moderately high specificity were attained.