Intraosseous Access in the Prehospital Setting: Literature Review

Fat intravasation, fat emboli and fat embolism syndrome in adult major trauma patients with intraosseous catheters: a systematic review

INTRODUCTION

Intraosseous (IO) administration of medication, fluids and blood products is accepted practice for critically injured patients in whom intravenous access is not immediately available. However, there are concerns that high intramedullary pressures resulting from IO infusion may cause bone marrow intravasation and subsequent fat embolisation. The aim of this systematic review is to synthesise the existing evidence describing fat intravasation, fat embolism and fat embolism syndrome (FES) following IO infusion.

METHODS

A systematic search of CINAHL, MEDLINE and Embase was undertaken using the search terms "intraosseous", "fat embolism", "fat intravasation" and "fat embolism syndrome". Two authors independently screened abstracts and full texts, against eligibility criteria and assessed risk of bias. A grey literature search (including references) was undertaken. Inclusion criteria were: all human and animal studies reporting novel data on IO-associated fat emboli. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

RESULTS

22 papers were identified from the search, with a further 5 found from reference lists. N=7 full papers met inclusion criteria. These papers were all translational animal studies. The overall risk of bias was high. Studies demonstrated that fat intravasation and fat embolisation are near universal after IO infusion, but of uncertain clinical significance. The initial IO flush appears to cause the highest intramedullary pressure and highest chance of fat intravasation and embolisation. No conclusions could be drawn on FES.

CONCLUSIONS

IO catheters remain a useful intervention in the armamentarium of trauma clinicians. Although their use is widely accepted, there is a paucity of evidence investigating fat embolisation in IO infusions. Despite this, pulmonary fat emboli after IO infusion are very common. The existing data are of low quality with a high risk of bias. More research is needed to address this important subject.

PROSPERO REGISTRATION NUMBER

CRD42023399333.

Systematic overview of intraosseous access versus intravenous delivery for emergency resuscitation: Efficacy and quality of existing evidence

BACKGROUND

The impact of intraosseous (IO) access on resuscitation outcomes, as compared to intravenous (IV) administration, is subject to ongoing debate. This review aims to provide a comprehensive evaluation of the methodological, reporting, and evidence quality of existing Systematic Reviews/Meta-Analyses (SRs/MAs) on IO use during resuscitation.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a strategic literature search to identify pertinent SRs/MAs published up until May 6th, 2023. After an extensive screening process, 4 SRs/MAs were included for review. We used the A Measurement Tool to Assess Systematic Reviews-2 tool for assessing methodological quality, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for evaluating reporting quality, and the Grading of Recommendations Assessment, Development, and Evaluation framework for examining the quality of evidence.

RESULTS

The assessment revealed high methodological quality across all the included SRs/MAs but showed significant variability in the quality of evidence. The studies offered conflicting findings on the impact of IO access on resuscitation outcomes such as return of spontaneous circulation, survival rates at hospital discharge, and favorable neurological outcomes. Some studies suggested an association of IO access with poorer outcomes, while others indicated no significant difference between IO and IV routes.

CONCLUSIONS

Despite the perceived utility of IO access when IV access is unachievable, the impact of IO on survival, return of spontaneous circulation, and neurological outcomes remains ambiguous due to the inconsistency in the existing evidence. This review underscores the critical need for more rigorous and consistent primary research in this area to strengthen clinical guidelines and improve patient outcomes.

Attitudes towards the Utilization of Intraosseous Access in Prehospital and Emergency Medicine Nursing Personnel

Background and Objectives: Insertion of an intraosseous access device enables intravascular access for critically ill patients in a prehospital and emergency department setting even when intravenous access is not possible. The aim of our study was to assess the attitudes of prehospital and emergency department nursing staff towards the utilization of intraosseous access devices. Materials and Methods: We performed quantitative research using a closed-ended structured questionnaire distributed to prehospital unit and associated emergency department nursing staff serving a population of around 200,000 inhabitants. Results: We distributed 140 questionnaires, and 106 were returned and completed. Of these, 69 (65.1%) respondents needed more than three attempts to achieve peripheral intravenous access at least once in the last year and 29 (27.4%) required central venous access because of impossible intravenous access. In the last five years, 8 (7.5%) respondents used endotracheal route for administration of medications. Despite this, only 48 (45.3%) of respondents have ever used the intraosseous route. Also, 79 (74.5%) respondents received at least some training in obtaining IO access; however, 46 (43.4%) answered that education regarding intraosseous access is not sufficient, and 92 (86.8%) answered that they wanted additional training regarding intraosseous access. Conclusions: Prehospital and emergency department nursing staff are aware of the importance of intraosseous access and understand the need for additional education and certification in this field.

Can Non-Physician Providers Use Ultrasound to Aid in Establishing Peripheral IV Access in Patients Who are Difficult to Cannulate? A Scoping Review

Introduction:

Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate.

Methods:

Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate.

Results:

A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians.

Conclusion:

Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

Peripheral intravenous catheter and intraosseous device insertions reported from the 1st July 2016 to 30th June 2017 in an Australian state ambulance service: An observational study

OBJECTIVE

To overcome the lack of larger, population-based studies reporting the prevalence of insertion of PIVCs and IO devices, and to describe the patient-related and service-related characteristics of these devices, inserted by paramedics, in an Australian state ambulance service.

METHODS

A retrospective analysis of the electronic Ambulance Report Form (medical record) and Computer Aided Dispatch system from the 1st July 2016 until 30th June 2017.

RESULTS

709,217 events were analysed. Of these, 20.4% involved at least one successful PIVC insertion and 0.07% involved at least one successful IO device insertion; most of the time on first attempt (89% and 86.4% respectively). Most PIVCs were inserted into the right antecubital fossa or dorsum of the right hand while IO devices were inserted into the proximal tibia. Of male patients, 21.4% received PIVCs while 19.5% of female patients received PIVCs. Very low numbers of both male and female patients received IOs (0.1%). Medical, non-traumatic presentations were the most common presentation and received the most insertions of both devices, followed by trauma presentations. Advanced Care Paramedics inserted 84.0% of PIVCs while Critical Care Paramedics inserted 94.4% of IO devices. Time treating and transporting patients generally increased with number of attempts at vascular access undertaken.

CONCLUSIONS

Queensland paramedic practices relating to insertion of PIVCs, and IO devices appears consistent with documented practice internationally. Further study is required to determine whether the antecubital fossa and dorsum of the hand insertions are clinically necessary in this population as areas of flexion and distal extremities are generally to be avoided for PIVC insertion.

Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices

Introduction: Obtaining successful vascular access is an essential component of the emergency and trauma setting. The modern practice of medicine advocates IO access for patients in a critical condition, especially when IV access is problematic or unobtainable. Various medical devices allowing for IO access have been coined and used in the management of critical patients.Areas covered: This study aims to review the literature regarding different intraosseous devices used to obtain vascular access (Bone Injection Gun (BIG), EZ-IO, NIO, Jamshidi, and First Access for Shock and Trauma (FAST-1) and discuss their clinical and experimental role in the emergency and trauma settings.Expert opinion: The development of medical technology contributes to an increasing number of intraosseous devices facilitating vascular access in challenging scenarios, including cardiopulmonary resuscitation, anaphylactic, or hypovolemic shock. Each of these devices provides an effective route for fluid resuscitation, drug delivery, laboratory evaluation, and shortening the timeframe for established vascular access, provided that the person obtaining the access is acquainted with the use of the device.

Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study

AIM

To compare outcomes between Intraosseous (IO) and peripheral intravenous (PIV) injection during in-hospital cardiac arrest (IHCA) and examine its utility in individuals with obesity.

METHODS

We performed a retrospective cohort analysis of adult, atraumatic IHCA at a single tertiary care center. Subjects were classified as either IO or PIV resuscitation. The primary outcome of interest was survival to hospital discharge. The secondary outcomes of interest were survival with favourable neurologic status, rates-of-ROSC (ROR) and time-to-ROSC (TTR). Subgroup analysis among patients with BMI ≥ 30 kg/m² was performed.

RESULTS

Complete data were available for 1852 subjects, 1039 of whom met eligibility criteria. A total of 832 were resuscitated via PIV route and 207 via IO route. Use of IO compared to PIV was associated with lower overall survival to hospital discharge (20.8% vs 28.4% p = 0.03), lower rates of survival with favourable neurologic status (18.4% vs 25.2% p = 0.04), lower ROR (72.2% vs 80.7%) and longer TTR (12:38 min vs 9:01 min). After multivariate adjustment there was no significant differences between IO and PIV in rates of survival to discharge (OR 0.71, 95% CI 0.47-1.06, p = 0.09) or rates of survival with favourable neurologic status (OR 0.74, 95% CI 0.49-1.13, p = 0.16). The ROR and TTR remained significantly worse in the IO group. Subgroup analysis of patients with BMI ≥ 30 kg/m² identified no benefit or harm with use of IO compared to PIV.

CONCLUSION

Intraosseous medication delivery is associated with inferior rates-of-ROSC and longer times-to-ROSC compared to PIV, but no differences in overall survival to hospital discharge or survival with favourable neurologic status during IHCA.

Prehospital use of peripheral intravenous catheters and intraosseous devices: An integrative literature review of current practices and issues

INTRODUCTION

Peripheral intravenous catheters and intraosseous devices have been widely used in the prehospital setting for a considerable period. Changes in technology and guidelines have led to an increase in situations where use of these devices in a prehospital setting is recommended. Despite being commonplace they are not without risk of harm to the patient.

STUDY OBJECTIVE

To examine critically the research-based literature related to incidence of insertion of peripheral intravenous catheters and intraosseous devices, the use of these vascular access devices and to determine which health professionals insert them, most commonly, in the prehospital setting.

METHODS

An integrative review was undertaken using material retrieved following a systematic search of research literature databases, grey literature and secondary sources written in English. No date limit was applied to the search and the searching was undertaken until September 2019. Articles specifically addressing peripheral intravenous catheter and intraosseous device use in the prehospital setting were selected.

RESULTS

The search resulted in 20 articles being included in the review, 17 related to peripheral intravenous catheters and three for intraosseous devices. All articles related to observational studies across a variety of services and settings.

CONCLUSION

The role of vascular access in the prehospital setting continues to be significant, particularly for patients who are critically unwell. This review identified that differences in service structure, geography and the patient's condition all impact on the insertion and use of these vascular access devices. Despite this there are limited data reported that can allow prehospital clinicians and services to benchmark their practice.

UK Helicopter Emergency Medical Services’ use of circulatory access devices, blood product transfusion and fluid warmers – a cross-sectional survey

Introduction

The pre-hospital environment provides significant challenges to clinicians who wish to rapidly administer warmed blood products and fluids to patients with haemorrhagic shock. Large-bore circulatory access is required with the use of devices that will successfully warm cold blood with minimal impact on flow rates. Until now, no information has been available that defines UK Helicopter Emergency Medical Services’ (HEMS) use of circulatory access and fluid warming devices, nor the recent adoption of pre-hospital blood product transfusion.

Methods

A survey was sent to all 22 UK HEMS asking which circulatory access devices crews have available, whether blood products are being transfused and if fluid warming devices are used as part of their resuscitations.

Results

All services responded. All UK HEMS use peripheral intravenous cannulae and intraosseous access. In addition, seven use central venous catheters and three use large-bore peripheral access (the Arrow Rapid Infusion Catheter®). Three services use landmark technique alone to gain central venous access, whereas four use a combination of landmark and ultrasound-guided techniques. Different sites for central venous access are used: subclavian (seven services), internal jugular (four) and femoral (four). Fourteen services carry pre-hospital blood products of which six transfuse packed red blood cells; four transfuse packed red blood cells and fresh frozen plasma; four transfuse packed red blood cells and lyophilised plasma. Eight services carry no pre-hospital blood products. Seventeen HEMS use fluid warmers; 13 use the Belmont® buddy lite™ and four use the QinFlow Warrior.

Conclusion

The use of a variety of policies and range of equipment has evolved across UK HEMS, demonstrating a lack of consensus on best practice. This is the first study to record a complete picture of current UK HEMS practice with regard to the use of circulatory access devices, fluid warmers and blood product administration.

Feasibility study of a novel intraosseous device in adult human cadavers

Background & objectives:

Intraosseous (IO) access is an alternative to difficult intravenous (iv) access during emergency clinical situations. Existing IO solutions are expensive, require power supply and trained manpower; limiting their use in resource constrained settings. To address these limitations, a novel IO device has been developed. The objectives of this study were to evaluate functionality and safety of this device in adult human cadavers.

Methods:

The ability of the IO device to penetrate the proximal and/or distal tibia was evaluated in three adult cadavers. Subjective parameters of loss of resistance, stable needle hold, easy needle withdrawal and any damage to the device were evaluated during the study. The insertion time was the objective parameter measured. Four sets of radiographs per insertion confirmed the position of the needle and identified complications.

Results:

A single physician performed 12 IO access procedures using the same device. Penetration of proximal and/or distal tibia was achieved in all instances. It was successful in the first attempt in eight (66.7%) and during second attempt in the remaining. The mean time to insertion was 4.1 ± 3.1 sec. Appropriate insertion of needle in the intra-medullary space of bone was confirmed with radiological examination in 10 (83.3%) insertions. In two occasions after penetrating the cortical layer of bone, the device overshot the intra-medullary space, as detected by radiological examination. Device got bent during insertion in one instance. There was no evidence of needle breakage or bone fracture. The needle could be withdrawn effortlessly in all instances.

Interpretation & conclusions:

The novel IO device could successfully penetrate the adult cadaver bones in most cases. Further studies are needed to confirm these results on a large sample.

Ketamine use in current clinical practice

After nearly half a century on the market, ketamine still occupies a unique corner in the medical armamentarium of anesthesiologists or clinicians treating pain. Over the last two decades, much research has been conducted highlighting the drug's mechanisms of action, specifically those of its enantiomers. Nowadays, ketamine is also being utilized for pediatric pain control in emergency department, with its anti-hyperalgesic and anti-inflammatory effects being revealed in acute and chronic pain management. Recently, new insights have been gained on ketamine's potential anti-depressive and antisuicidal effects. This article provides an overview of the drug's pharmacokinetics and pharmacodynamics while also discussing the potential benefits and risks of ketamine administration in various clinical settings.

Pre-hospital emergency medicine

Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.

EZ-IO(®) intraosseous device implementation in German Helicopter Emergency Medical Service

BACKGROUND

Intraosseous access (IO) is a rapid and safe alternative when peripheral venous access is difficult. Our aim was to summarize the first three years experience with the use of a semi-automatic IO device (EZ-IO(®)) in German Helicopter Emergency Medical Service (HEMS).

METHODS

Included were all patients during study period (January 2009-December 2011) requiring an IO access performed by HEMS team. Outcome variables were IO rate, IO insertion success rates, site of IO access, type of EZ-IO(®) needle set used, strategy of vascular access, procedure related problems and operator's satisfaction.

RESULTS

IO rate was 0.3% (348/120.923). Overall success rate was 99.6% with a first attempt success rate of 85.9%; there was only one failure (0.4%). There were three insertion sites: proximal tibia (87.2%), distal tibia (7.5%) and proximal humerus (5.3%). Within total study group IO was predominantly the second-line strategy (39% vs. 61%, p<0.001), but in children<7 years, in trauma cases and in cardiac arrest IO was more often first-line strategy (64% vs. 28%, p<0.001; 48% vs. 34%, p<0.032; 50% vs. 29%, p<0.002 respectively). Patients with IO access were significantly younger (41.7±28.7 vs. 56.5±24.4 years; p<0.001), more often male (63.2% vs. 57.7%; p=0.037), included more trauma cases (37.3% vs. 30.0%; p=0.003) and more often patients with a NACA-Score≥5 rating (77.0% vs. 18.6%; p<0.001). Patients who required IO access generally presented with more severely compromised vital signs associated with the need for more invasive resuscitation actions such as intubation, chest drains, CPR and defibrillation. In 93% EZ-IO(®) needle set handling was rated "good". Problems were reported in 1.6% (needle dislocation 0.8%, needle bending 0.4% and parafusion 0.4%).

CONCLUSIONS

The IO route was generally used in the most critically ill of patients. Our relatively low rate of usage would indicate that this would be compatible with the recommendations of established guidelines. The EZ-IO(®) intraosseous device proved feasible with a high success rate in adult and pediatric emergency patients in HEMS.

Fat Intravasation from Intraosseous Flush and Infusion Procedures

STUDY HYPOTHESIS

The primary study objective was to delineate the procedural aspects of intraosseous (IO) infusions responsible for fat intravasation by testing the hypothesis that the fat content of effluent blood increases during IO infusions.

METHODS

IO cannulas were inserted into the proximal tibiae of 35 anesthetized swine (Sus scrofa, 50.1 ± 3.5 kg) and intravasated fat was assessed using a lipophilic fluoroprobe (Nile red) and by vascular ultrasound imaging. Effluent blood bone marrow fat was assessed at baseline, during flush, and with regimens of controlled infusion pressures (73-300 mmHg) and infusion flow rates (0.3-3.0 mL per second). Fat intravasation was also assessed with IO infusions at different tibial cannulation sites and in the distal femur. In 7 animals, the lipid uptake of alveolar macrophages and lung tissue assessed for fat embolic burden using oil red O stain 24 hours post infusion. Additionally, bone marrow shear-strain was assessed radiographically with IO infusions.

RESULTS

Fat intravasation was observed during all IO infusion regimens, with subclinical pulmonary fat emboli persisting 24 hours post infusion. It was noted that initial flush was a significant factor in fat intravasation, low levels of intravasation occurred with infusions ≤300 mmHg, fat intravasation and bone marrow shear-strain increased with IO infusion rates, and intravasation was influenced by cannula insertion site. Ultrasound findings suggest that echogenic particles consistent with fat emboli are carried in fast and slow venous blood flow fields. Echo reflective densities were observed to rise to the nondependent endovascular margins and coalesce in accordance with Stoke's law. In addition, ultrasound findings suggested that intravasated bone marrow fat was thrombogenic.

CONCLUSION

Results suggest that in swine the intravasation of bone marrow fat is a common consequence of IO infusion procedures and that its magnitude is influenced by the site of cannulation and infusion forces. Although the efficacy and benefits of IO infusions for emergent care are well established, emergency care providers also should be cognizant that infusion procedures affect bone marrow fat intravasation.

Comparison of 3 different intraosseous access devices for adult during resuscitation. Randomized crossover manikin study

BACKGROUND

The study was designed to investigate the success rate and time of insertion intraosseous access during simulated resuscitation.

MATERIAL AND METHODS

This was a randomized crossover study involving 107 paramedics. They were timed from start of insertion attempt to successful insertion and asked to score perceived difficulty of intraosseus access devices. Bone injection gun (BIG) (WaisMed Company, Houston, TX), EZ-IO (Vidacare, Shavano Park, TX) and Jamshidi (Carefusion, San Diego, CA) were used in this study.

RESULTS

Success rates for first intraosseus iniecition attempt were higher for the BIG (91.59%) than EX-IO (82.66%) or Jamshidi (47.66%). Mean procedure time was 2.0±0.7 vs 3.1±0.9 minutes for EZ-IO vs 4.2±1.0 minutes for Jamshidi.

CONCLUSIONS

The use of BIG is associated with excellent success rates for insertion and appears easier to use than EZ-IO or Jamshidi Intraosseus Needle. Further work to evaluate the use of the intraosseus access device in the emergency medical services is required.

Videos in clinical medicine. Insertion of an intraosseous needle in adults

Intraosseous needle insertion is used as a temporary measure when intravascular access cannot be achieved through peripheral or central venous routes. The intraosseous needle may remain in situ for 72 to 96 hours, but it is best removed within 6 to 12 hours, as soon as an alternative site of intravascular access has been established. The intraosseous route provides fast and reliable vascular access in emergency medical situations. The use of the appropriate technique will ensure that the procedure is performed as safely and effectively as possible.

Anatomy of sodium hypochlorite accidents involving facial ecchymosis - a review

OBJECTIVES

Root canal treatment forms an essential part of general dental practice. Sodium hypochlorite (NaOCl) is the most commonly used irrigant in endodontics due to its ability to dissolve organic soft tissues in the root canal system and its action as a potent antimicrobial agent. Although NaOCl accidents created by extrusion of the irrigant through root apices are relatively rare and are seldom life-threatening, they do create substantial morbidity when they occur.

METHODS

To date, NaOCl accidents have only been published as isolated case reports. Although previous studies have attempted to summarise the symptoms involved in these case reports, there was no endeavour to analyse the distribution of soft tissue distribution in those reports. In this review, the anatomy of a classical NaOCl accident that involves facial swelling and ecchymosis is discussed.

RESULTS

By summarising the facial manifestations presented in previous case reports, a novel hypothesis that involves intravenous infusion of extruded NaOCl into the facial vein via non-collapsible venous sinusoids within the cancellous bone is presented.

CONCLUSIONS

Understanding the mechanism involved in precipitating a classic NaOCl accident will enable the profession to make the best decision regarding the choice of irrigant delivery techniques in root canal débridement, and for manufacturers to design and improve their irrigation systems to achieve maximum safety and efficient cleanliness of the root canal system.

Ketamine: use in anesthesia

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.

EZ-IO(®) intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature

INTRODUCTION

Intraosseous access is increasingly recognised as an effective alternative vascular access to peripheral venous access. We aimed to prospectively study the patients receiving prehospital intraosseous access with the EZ-IO(®), and to compare our results with those of the available literature.

METHODS

Every patient who required an intraosseous access with the EZ-IO from January 1st, 2009 to December 31st, 2011 was included. The main data collected were: age, sex, indication for intraosseous access, localisation of insertion, success rate, drugs and fluids administered, and complications. All published studies concerning the EZ-IO device were systematically searched and reviewed for comparison.

RESULTS

Fifty-eight patients representing 60 EZ-IO procedures were included. Mean age was 47 years (range 0.5-91), and the success rate was 90%. The main indications were cardiorespiratory arrest (74%), major trauma (12%), and shock (5%). The anterior tibia was the main route. The main drugs administered were adrenaline (epinephrine), atropine and amiodarone. No complications were reported. We identified 30 heterogeneous studies representing 1603 EZ-IO insertions. The patients' characteristics and success rate were similar to our study. Complications were reported in 13 cases (1.3%).

CONCLUSION

The EZ-IO provides an effective way to achieve vascular access in the pre-hospital setting. Our results were similar to the cumulative results of all studies involving the use of the EZ-IO, and that can be used for comparison for further studies.