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Desai KK, Mann AJ, Azar F, Lottenberg L, Borrego R. Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report. Cureus 2023; 15:e50248. [PMID: 38196424 PMCID: PMC10774495 DOI: 10.7759/cureus.50248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/11/2024] Open
Abstract
Obtaining adequate vascular access is imperative for effective resuscitative, therapeutic, and diagnostic interventions. The intraosseous (IO) route is indicated when immediate vascular access is needed, and standard central or peripheral intravenous (IV) access is unattainable or would delay therapy in a critical patient. We present a rare case of improper IO line placement in the right proximal tibia of a 30-year-old female involved in a motor vehicle collision, resulting in extravasation of blood products into the surrounding tissue and development of acute compartment syndrome. Emergency Medical Services was unable to obtain IV access in a timely manner, thus a right proximal tibia 45mm IO line was placed, and a unit of whole blood was given with a high-pressure infusor in the field. At the trauma center, the patient's right lower extremity was severely tense and edematous with no palpable right lower extremity pulses and no Doppler signals. Computed tomography revealed the IO catheter extending through both the proximal and distal cortices of the right tibia. Medial and lateral fasciotomy of the right lower extremity was performed in which all four compartments of the right lower leg were released and a significant hematoma was evacuated from the superficial posterior compartment. This case highlights the importance of IO access as a life-saving intervention while also underscoring the need to educate and familiarize pre-hospital and hospital healthcare personnel in delivering IO access so as to mitigate risks and improve outcomes for critically ill patients.
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Affiliation(s)
- Kishan K Desai
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Adam J Mann
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Faris Azar
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Lawrence Lottenberg
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Robert Borrego
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
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Mockler S, Metelmann C, Metelmann B, Thies KC. Prevalence and severity of pediatric emergencies in a German helicopter emergency service: implications for training and service configuration. Eur J Pediatr 2023; 182:5057-5065. [PMID: 37656240 PMCID: PMC10640406 DOI: 10.1007/s00431-023-05178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
This study primarily aims to determine the frequency of life-threatening conditions among pediatric patients served by the DRF, a German helicopter emergency service (HEMS) provider. It also seeks to explore the necessity of invasive procedures in this population, discussing the implications for HEMS crew training and service configuration based on current literature. We analyzed the mission registry from 31 DRF helicopter bases in Germany, focusing on 7954 children aged 10 or younger over a 5-year period (2014-2018). Out of 7954 identified children (6.2% of all primary missions), 2081 (26.2%) had critical conditions. Endotracheal intubation was needed in 6.5% of cases, while alternative airway management methods were rare (n = 14). Half of the children required intravenous access, and 3.6% needed intraosseous access. Thoracostomy thoracentesis and sonography were only performed in isolated cases. Conclusions: Critically ill or injured children are infrequent in German HEMS operations. Our findings suggest that the likelihood of HEMS teams encountering such cases is remarkably low. Besides endotracheal intubation, life-saving invasive procedures are seldom necessary. Consequently, we conclude that on-the-job training and mission experience alone are insufficient for acquiring and maintaining the competencies needed to care for critically ill or injured children. What is Known: • Pediatric emergencies are relatively rare in the prehospital setting, but their incidence is higher in helicopter emergency medical services (HEMS) compared to ground-based emergency services. What is New: • On average, HEMS doctors in Germany encounter a critically ill or injured child approximately every 1.5 years in their practice, establish an IV or IO access in infants or toddlers every 2 years, and intubate an infant every 46 years. • This low frequency highlights the insufficiency of on-the-job training alone to develop and maintain pediatric skills among HEMS crews. Specific interdisciplinary training for HEMS crews is needed to ensure effective care for critically unwell pediatric patients.
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Affiliation(s)
- Stefan Mockler
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany.
| | - Camilla Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Bibiana Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Karl Christian Thies
- Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Campus Bielefeld Bethel, Burgsteig 13, 33617, Bielefeld, Germany
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Kay VC, Gehrz JA, Grady DW, Emerling AD, McGowan A, Reilly ER, Bebarta VS, Nassiri J, Vinals J, Schrader A, Zarow GJ, Auten JD. Application Times, Placement Accuracy, and User Ratings of Commercially Available Manual and Battery-Powered Intraosseous Catheters in a High Bone Density Cadaveric Swine Model. Mil Med 2023:usad407. [PMID: 37897689 DOI: 10.1093/milmed/usad407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/21/2023] [Accepted: 10/07/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating trauma patients with severe hemorrhage. However, little is known regarding the application times, placement accuracy, and end-user ratings of battery-powered and manual IO access devices. This study was specifically designed to fill these knowledge gaps on six FDA-approved IO access devices. MATERIALS AND METHODS Three experienced U.S. Navy Emergency Medicine residents each placed commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums in a randomized prospective experimental design. Devices included the battery-powered EZ-IO Rapid Infuser and the manual Jamshidi IO, PerSys NIO, SAM Manual IO, Tactical Advanced Lifesaving IO Needle (TALON), and PYNG First Access for Shock and Trauma 1 (30 trials per device, 10 per user, 210 total trials). Application times, placement accuracy in medullary (zone 1) and trabecular (zone 2) bone while avoiding cortical (zone 3) bone, and eight subjective user ratings were analyzed using ANOVA and nonparametric statistics at P < .05. RESULTS The EZ-IO demonstrated the fastest application times, high rates in avoiding zone 3, and the highest user ratings (P < .0001). The TALON conferred intermediate placement times, highest rates of avoiding zone 3, and second-highest user ratings. The SAM Manual IO and Jamshidi performed poorly, with mixed results for the PerSys NIO and PYNG First Access for Shock and Trauma 1. CONCLUSIONS The battery-powered EZ-IO performed best and remains the IO access device of choice. The present findings suggest that the TALON should be considered as a manual backup to the EZ-IO.
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Affiliation(s)
- Victoria C Kay
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Joseph A Gehrz
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Derek W Grady
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Alec D Emerling
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Andrew McGowan
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Erin R Reilly
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Joshua Nassiri
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jorge Vinals
- School of Physics and Astronomy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Andrew Schrader
- Division of Animal Resources, NMCSD San Diego, San Diego, CA 92134, USA
| | - Gregory J Zarow
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- The Emergency Statistician, Idyllwild, CA 92549, USA
| | - Jonathan D Auten
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Drozd A, Wolska M, Szarpak L. Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices. Expert Rev Med Devices 2021; 18:855-864. [PMID: 34325586 DOI: 10.1080/17434440.2021.1962287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Anna Drozd
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland
| | - Marta Wolska
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
| | - Lukasz Szarpak
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland.,Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland.,Outcomes Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, Bialystok, Poland
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Drozd A, Smereka J, Pruc M, Malysz M, Gasecka A, Sonmez LO, Cyran M, Konge L, Szarpak L. Comparison of intravascular access methods applied by nurses wearing personal protective equipment in simulated COVID-19 resuscitation: A randomized crossover simulation trial. Am J Emerg Med 2021; 49:189-194. [PMID: 34126564 PMCID: PMC8172272 DOI: 10.1016/j.ajem.2021.05.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/03/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Prehospital emergency care of children is challenging. In the era of the COVID-19 pandemic, when medical personnel should use personal protective equipment against aerosol-generating procedures, the efficiency of medical procedures may decrease. The study objective was to evaluate the effectiveness of different intravascular access methods applied by nurses wearing biosafety Level-2 suits in simulated paediatric COVID-19 resuscitation. METHODS A prospective, randomized, crossover, single-blinded simulation trial was performed. Nursing staff attending Advanced Cardiovascular Life Support courses accredited by the American Heart Association participated in the study. A total of 65 nurses were recruited and randomly assigned to different study groups. They received standard training on intravascular access methods employing distinct devices. The participants wore biosafety Level-2 suits and performed vascular access with the following intraosseous devices: NIO-P, EZ-IO, and Jamshidi needle; intravenous (IV) access was used as a reference method. Both the order of participants and the access methods were random. Each participant performed intravascular access with each of the four methods tested. The effectiveness of the first attempt to obtain intravascular access and the following time parameters were analysed: the time between grasping the intravascular device out of the original packing until infusion line connection. The ease of the procedure was measured with a visual analogue scale (1 - easy; 10 - difficult). RESULTS The first attempt success rate of intravascular access by using NIO-P and EZ-IO equalled 100% and was statistically significantly higher than that with the Jamshidi needle (80.0%; p = 0.02) and with the IV method (69.2%; p = 0.005). The time required to connect the infusion line varied and amounted to 33 ± 4 s for NIO-P compared to 37 ± 6.7 s for EZ-IO (p<0.001), 43 ± 7 s for Jamshidi (p<0.001), and 98.5 ± 10 s for IV access (p<0.001). The procedure was easiest in the case of NIO-P and EZ-IO (2 ± 1 points; p=1.0) compared with Jamshidi (5 ± 3 points; p<0.001) and IV access (7 ± 2 points; p<0.001). CONCLUSION The study provides evidence that nurses wearing biosafety Level-2 suits were able to obtain intraosseous access faster and more effectively as compared with IV access during simulated COVID-19 paediatric resuscitation. The most effective method of intravascular access was the NIO-P intraosseous device. Further clinical trials are necessary to confirm the results.
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Affiliation(s)
- Anna Drozd
- Polish Society of Disaster Medicine, Warsaw, Poland
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
| | - Michal Pruc
- Polish Society of Disaster Medicine, Warsaw, Poland
| | - Marek Malysz
- Polish Society of Disaster Medicine, Warsaw, Poland
| | - Aleksandra Gasecka
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Leyla Ozturk Sonmez
- Department of Emergency Medicine, Beyhekim Training and Research Hospital, Konya, Turkey
| | - Maciej Cyran
- Maria Sklodowska-Curie Medical Academy in Warsaw, Poland
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, University of Copenhagen, Copenhagen, Denmark
| | - Lukasz Szarpak
- Polish Society of Disaster Medicine, Warsaw, Poland; Maria Sklodowska-Curie Bialystok Oncology Center, Bialystok, Poland.
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