The Use of a Powered Device for Intraosseous Drug and Fluid Administration in a National EMS: A 4-Year Experience

EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience

OBJECTIVE

Access of intraosseous (IO) compartments is a commonly used technique that is an invaluable asset in emergency resuscitation. Prehospital IO success rates using semi-automatic insertion devices vary between 70 and 100% of pediatric patients. There are limited data on time to insertion and duration of IO function in the prehospital setting. Recent studies limited to the pediatric emergency department (PED) setting have also suggested that IOs may be less successful in the infant population. We explored the use of IO access for pediatric resuscitation, encompassing the prehospital and pediatric emergency department (PED) settings.

METHODS

This is a retrospective review of emergency medical services (EMS) patient care reports and PED data of patients aged 0-17 years old and transported by regional ground EMS agencies in Southwestern Ontario, Canada from 2012 to 2019. Mean and median time to first insertion and IO function (from insertion to IO failure, IV access, transfer to ICU, or death) were calculated.

RESULTS

Successful prehospital IO access was achieved in 83.7% of patients. The median time required to achieve IO access was 4 min (IQR 3-7) and mean duration of IO function was 27.6 min (SD: 14.8). Patients less than 1 year old had fewer functional IOs (25.9% vs. 75.0%), more insertion attempts (2 vs. 1), and shorter duration of IO function (18.8 vs. 32.2 mins) than the older age group (p < 0.05).

CONCLUSIONS

This is the first study to provide time to IO access and IO duration in the prehospital setting, and the first prehospital evidence to suggest inferior IO function in infants <1 year old, compared to other ages. This highlights unique challenges for infants that have implications for the PED, interfacility transport, and critical care settings.

A Serious Adult Intraosseous Catheter Complication and Review of the Literature

OBJECTIVE

Current guidelines recommend the use of intraosseous access when IV access is not readily attainable. The pediatric literature reports an excellent safety profile, whereas only small prospective studies exist in the adult literature. We report a case of vasopressor extravasation and threatened limb perfusion related to intraosseous access use and our management of the complication. We further report our subsequent systematic review of intraosseous access in the adult population.

DATA SOURCES

Ovid Medline was searched from 1946 to January 2015.

STUDY SELECTION

Articles pertaining to intraosseous access in the adult population (age greater than or equal to 14 years) were selected. Search terms were "infusion, intraosseous" (all subfields included), and intraosseous access" as key words.

DATA EXTRACTION

One author conducted the initial literature review. All authors assessed the methodological quality of the studies and consensus was used to ensure studies met inclusion criteria.

DATA SYNTHESIS

The case of vasopressor extravasation was successfully treated with pharmacologic interventions, which reversed the effects of the extravasated vasopressors: intraosseous phentolamine, topical nitroglycerin ointment, and intraarterial verapamil and nitroglycerin. Our systematic review of the adult literature found 2,332 instances of intraosseous insertion. A total of 2,106 intraosseous insertion attempts were made into either the tibia or the humerus; 192 were unsuccessful, with an overall success rate of 91%. Five insertions were associated with serious complications. A total of 226 insertion attempts were made into the sternum; 54 were unsuccessful, with an overall success rate of 76%.

CONCLUSIONS

Intraosseous catheter insertion provides a means for rapid delivery of medications to the vascular compartment with a favorable safety profile. Our systematic literature review of adult intraosseous access demonstrates an excellent safety profile with serious complications occurring in 0.3% of attempts. We report an event of vasopressor extravasation that was potentially limb threatening. Therapy included local treatment and injection of intraarterial vasodilators. Intraosseous access complications should continue to be reported, so that the medical community will be better equipped to treat them as they arise.

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.

Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult Emergencies, the CITRIN (Comparison of InTRaosseous infusion systems in emergency medicINe)-Study

INTRODUCTION

Intraosseous infusion is recommended if peripheral venous access fails for cardiopulmonary resuscitation or other medical emergencies. The aim of this study, using body donors, was to compare a semi-automatic (EZ-IO®) device at two insertion sites and a sternal intraosseous infusion device (FASTR™).

METHODS

Twenty-seven medical students being inexperienced first-time users were randomized into three groups using EZ-IO and FASTR. The following data were evaluated: attempts required for successful placement, insertion time and flow rates with and without external pressure to the infusion.

RESULTS

The first-pass insertion success of the EZ-IO tibia, EZ-IO humerus and FASTR was 91%, 77%, and 95%, respectively. Insertion times (MW ± SD) did not show significant differences with 17 ± 7 (EZ-IO tibia) vs. 29 ± 42 (EZ-IO humerus) vs. 33 ± 21 (FASTR), respectively. One-minute flow rates using external pressures between 0 mmHg and 300 mmHg ranged between 27 ± 5 to 69 ± 54 ml/min (EZ-IO tibia), 16 ± 3 to 60 ± 44 ml/min (EZ-IO humerus) and 53 ± 2 to 112 ± 47 ml/min (FASTR), respectively. Concerning pressure-related increases in flow rates, negligible correlations were found for the EZ-IO tibia in all time frames (c = 0.107-0.366; p ≤ 0.013), moderate positive correlations were found for the EZ-IO humerus after 5 minutes (c = 0.489; p = 0.021) and strong positive correlations were found for the FASTR in all time frames (c = 0.63-0.80; p ≤ 0.007). Post-hoc statistical power was 0.62 with the given sample size.

CONCLUSIONS

The experiments with first-time users applying EZ-IO and FASTR in body donors indicate that both devices may be effective intraosseous infusion devices, likely suitable for fluid resuscitation using a pressure bag. Variations in flow rate may limit their reliability. Larger sample sizes will prospectively be required to substantiate our findings.

Vascular access through the intraosseous route in pediatric emergencies

Obtaining venous access in critically ill children is an essential procedure to restore blood volume and administer drugs during pediatric emergencies. The first option for vascular access is through a peripheral vein puncture. If this route cannot be used or if a prolonged period of access is necessary, then the intraosseous route is an effective option for rapid and safe venous access. The present work is a descriptive and exploratory literature review. The study's aim was to describe the techniques, professional responsibilities, and care related to obtaining venous access via the intraosseous route in pediatric emergencies. We selected 22 articles (published between 2000 and 2011) that were available in the Latin American and Caribbean Health Sciences (LILACS) and MEDLINE databases and the SciELO electronic library, in addition to the current protocol of cardiopulmonary resuscitation from the American Heart Association (2010). After the literature search, data were pooled and grouped into the following categories of analysis: historical aspects and physiological principles; indications, benefits, and contraindications; professional assignments; technical principles; care during the access; and possible complications. The results of the present study revealed that the intraosseous route is considered the main secondary option for vascular access during the emergency response because the technique is quick and easily executed, presents several non-collapsible puncture sites, and enables the rapid and effective administration of drugs and fluid replacement.

Pre-hospital intra-osseous freeze dried plasma transfusion: a case report

Background

Hemorrhage and coagulopathy are among the leading causes of death in combat and are considered the leading causes of preventable deaths. Plasma, in the form of Fresh Frozen Plasma (FFP) is considered a key component in the Damage Control Resuscitation performed within hospitals. Freeze-Dried Plasma (FDP) can be stored at room temperature and therefore is potentially useful in pre-hospital conditions. Our case report join to few cases where FDP was administered at the point of injury. It is also unique as it describes an intra- osseous administration given to pediatric patient.

Case report

M.S. otherwise healthy 13 year old girl was injured due to gunshots and grenade blast. On the first triage by the IDF medical teams she suffered from: Severe hemorrhagic shock, (Blood pressure could not be measured, Heart rate 163), superficial wounds to her face, (forehead and Rt. Eye), gunshot wounds with active bleeding from her Lt. Arm and her RT. Knee (Mangled Extremity Severity Score (MESS) 8) and open fractures of left elbow and right thigh. A peripheral intravenous catheter was established and 1 g tranexamic acid in 500 ml of Hartman fluid were administered. Due to difficulties in establishing a functioning intra-venous line, an intra-osseous catheter was established and one unit of FDP (250 ml) was given in the field. She was transferred by a military medical team to a regional civilian hospital for further treatment. Upon arrival to the hospital her blood pressure and heart rate were significantly improved. After three weeks of hospitalization M.S. was discharged and she was returned to her homeland.

Conclusion

We have described the successful use of FDP for pre hospital resuscitation of a 13 year old girl suffering from severe hemorrhagic shock as a result of gunshots and grenade blast. This case report demonstrates that intra-osseous FDP administration for as part pre hospital resuscitation of children has a favorable outcome.

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.

Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access

OBJECTIVE

Intraosseous access (IO) is becoming increasingly accepted in adult populations as an alternative to peripheral vascular access; however, there is still insufficient evidence in large patient groups supporting its use.

METHODS

Retrospective review. This paper reports on the use of IO devices over a 7-year period from August 2006 to August 2013 during combat operations in Afghanistan. A database search of the Joint Theatre Trauma Registry (JTTR) was carried out looking for all the incidences of IO access use during this time. Excel (Microsoft) was used to manage the dataset and perform descriptive statistics on the patient demographics, injuries, treatments and complications that were retrieved.

RESULTS

1014 IO devices were used in 830 adult patients with no major complications. The rate of minor complications, the majority of which were device failure, was 1.38%. 5124 separate infusions of blood products or fluids occurred via IO access, with 36% being of packed red cells. On average, each casualty received 6.95 different infusions of blood products and fluids, and 3.28 separate infusions of drugs through IO access. 32 different drugs were infused to 367 patients via IO, the most frequent being anaesthetic agents. IO access was used in the prehospital environment, during tactical helicopter evacuation and within hospitals.

CONCLUSIONS

IO access can be used to administer a wide variety of life-saving medications quickly, easily and with low-complication rates. This highlights its valuable role as an alternative method of obtaining vascular access, vital when resuscitating the critically injured trauma patient.

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.

Educational effect of intraosseous access for medical students

PURPOSE

The purpose of this study was to determine the educational effects of intraosseous (IO) vascular access for medical students and analyze the possibility of including IO access in medical education.

METHODS

A before-and-after study was conducted in a course with 50 participating medical students. The course comprised a 1-hour didactic lecture and a 1-hour hands-on session with a battery-operated EZ-IO device (Vidacare Corp.) and artificial tibia. After the course, the participant skills were tested (final success rate, mean procedural time, and detailed skills) with regard to IO access. Before and after the course, the knowledge, possibility of clinical use, and adequacy of medical education on IO access were examined in a structured questionnaire.

RESULTS

The final success rate of insertion was 88% (n=44), and the mean procedural time for the first trial was 78.1±20.6 seconds. "Combination needle with drill" and "proper angle during insertion" were the procedures that were performed the best, and "dressing on insertion site" was the worst-performed procedure. "Proper location of landmarks" was the only significant skill factor that was related to the success of IO access between those who succeeded and failed (p<0.05). In the analysis of the structured questionnaire, median knowledge score, possibility for clinical use, and adequacy of IO access in medical education increased significantly after the course (p<0.01).

CONCLUSION

The educational effect of IO access for medical students was tremendous, and the knowledge of and attitude toward IO access improved significantly after the training course. We consider IO access to be adequate for medical education in Korea.

Intraosseous Vascular Access is Safe, Effective and Costs less than Central Venous Catheters for Patients in the Hospital Setting

Purpose

Central venous catheters (CVCs) are often placed to resuscitate unstable emergency department (ED) patients. In an observational study, we assessed intraosseous (IO) vascular access in the hospital, and compared results to published experiences with CVC placement.

Methods

Patients who would typically receive a CVC were considered for the study. Vascular access was gained using a powered IO device. Data collection included placement success, placement time, ease-of-use, satisfaction with flow rates, complications and subsequent CVC placement.

Results

A total of 105 cases were studied from six centers. Mean age was 48.0±28.0 years and 53% were men; 85% of the patients were medical cases, and 53% were in cardiac/respiratory arrest. Of those, 48% returned to spontaneous circulation. A total of 94% of placements were successful on the first attempt. Mean time to IO access was 103.6±96.2 seconds. There was one serious complication – a lower extremity compartment syndrome. IO access costs $100/patient.

Conclusions

The data revealed faster and more successful IO catheter placement than reported for CVCs, few complications and high user satisfaction. For simple placements, cost savings for IO access vs. CVCs was $195/procedure. If 20% of the 3.5 million CVCs placed annually were replaced with IO catheters, cost savings could approach $650 million/year. We conclude that IO access in place of CVCs delivers high value in terms of being a safe, fast and effective mode of vascular access for patients in the hospital setting, with potentially substantial cost savings. These data indicate that IO access is a cost effective and viable alternative to problematic CVC lines.

Powered intraosseous device (EZ-IO) for critically ill patients

We reviewed the charts of 25 patients who underwent powered intraosseous line insertion between July 1, 2008 and August 31, 2010 to determine its users, indications, procedural details, success rates, and complications. Intraosseous (IO) line was inserted in the anteromedial aspect of the proximal tibia in all patients. The first attempt was successful in 80%, and the median duration for insertion of the IO line was 4 hours. Extravasation was the most common complication. Ninety-six percent of the physicians had undergone prior training in IO insertion. Because of its high success and short procedure time, IO access should be the first alternative to failed vascular access in critically ill children. Training in IO should be extended to all who care for pediatric patients in inpatient as well as in prehospital and emergency department settings.

Intraosseous Access in the Prehospital Setting: Literature Review

Background

Although the majority of Australian intensive care paramedics use the manual intraosseous infusion technique (MAN-IO), several other semiautomatic devices now are available, such as the bone injection gun (BIG) and the semiautomatic intraosseous infusion system (EZ-IO). Given the choice of devices now available, questions have been raised regarding success rates, accuracy, decay of skills, and adverse events.

Objectives

Review the literature regarding the use of intraosseous (IO) devices in the prehospital setting.

Methods

Selected electronic databases (Medline, Embase, and CINAHL) were searched, and a hand search was conducted for grey-literature that included studies from the commencement of the process to the end of May 2010. Inclusion criteria were any study reporting intraosseous insertion and/or infusion (adult and pediatric) by paramedics in the prehospital setting.

Findings

The search located 2,100 articles; 20 articles met the inclusion criteria. The review also noted that use of IO access (regardless of technique) offers a safe and simple method for gaining access to the patients’ vascular system. A number of studies found that the use of semiautomatic devices offers better and faster intraosseous access compared with the use of manual devices, and also were associated with fewer complications. The findings also suggest that the use of semiautomatic devices can reduce insertion times and the number of insertion attempts when contrasted with the use of manual insertion techniques. Despite these findings, statistically no specific IO device has proven clinical superiority.

Conclusion

While manual IO techniques currently are used by the majority of Australian paramedics, the currently available evidence suggests that semiautomatic devices are more effective. Further research, including cost-benefit analyses, is required at a national level to examine skill acquisition, adverse effects, and whether comparative devices offer clinically significant advantages.

OlaussenA, WilliamsB. Intraosseous access in the prehospital setting: literature review. Prehosp Disaster Med.2012;27(5):1-5.

Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis

Intraosseous (IO) vascular access is a viable primary alternative in patients requiring emergent vascular access in the hospital emergency department (ED) (eg, resuscitation, shock/septic shock) but is underutilized.

OBJECTIVES

This review has 3 objectives: (1) review the evidence supporting the use of IO access; (2) determine the utilization of IO access as described in the literature; and (3) assess the level of specialty society support.

METHODS

Electronic and hand searches were undertaken to identify relevant articles. English-language-only articles were identified. The Cochrane Review methodology along with data forms were used to collect and review data. The evidence evaluation process of the international consensus on emergency cardiovascular care was used to assess the evidence. Studies were combined where meta-analyses could be performed.

RESULTS

In levels 2 to 5 studies, IO access performed better versus alternative access methods on the end points of time to access and successful access. Complications appeared to be comparable to other venous access methods. Randomized controlled trials are lacking. Newer IO access technologies appear to do a better job of gaining successful access more quickly. Intraosseous access is underutilized in the ED because of lack of awareness, lack of guidelines/indications, proper training, and a lack of proper equipment.

CONCLUSIONS

Recommendations/guidelines from physician specialty societies involved in the ED setting are also lacking. Underutilization exists despite recommendations for IO access use from a number of important medical associations peripherally involved in the ED such as the American Academy of Pediatrics. To encourage the IO approach, IO product champions (as both supporter and user) in the ED are needed for prioritizing and assigning IO access use when warranted. In addition, specialty societies directly involved in emergent hospital care should develop clinical guidelines for IO use.

Current status of establishing a venous line in CPA patients by Emergency Life-Saving Technicians in the prehospital setting in Japan and a proposal for intraosseous infusion

INTRODUCTION

It is important to have a venous line in cardiopulmonary arrest (CPA) patients as an emergency treatment measure in prehospital settings, but establishment of a peripheral venous line is difficult in such patients. This study aimed to investigate the current status of intravenous infusion (IVI) in CPA patients by Emergency Life-Saving Technicians (ELSTs) in Japan. We also considered alternative measures in case IVI was difficult or impossible.

METHODS

We investigated a nationwide database between 1 January 2005 and 31 December 2008. From a total of 431,968 CPA cases, we calculated the IVI success rate and related parameters.The Bone Injection Gun (BIG) and simulator legs (adult, pediatric, and infant) were used by 100 ELSTs selected for the study to measure the time required and the success rate for intraosseous infusion (IOI).

RESULTS

The number of CPA patients, IVI, adrenaline administration, and the IVI success rate in adult CPA patients increased every year. However, the IVI success rate in pediatric CPA patients did not increase. Although adrenaline administration elevated the ROSC rate, there was no improvement in the 1-month survival rate. The time required for IOI with BIG was not different among the leg models. The success rates of IOI with BIG were 93%, 94%, and 84% (p < 0.05 vs. adult and pediatric) in adult, pediatric, and infant models, respectively.

CONCLUSIONS

The rate of success of IVI in adult CPA patients has been increased yearly in Japan. However, as establishing a peripheral venous line in pediatric patients (1-7 years old) by ELSTs is extremely difficult in prehospital settings, there was no increase in the IVI success rate in such patients. As the study findings indicated IOI with BIG was easy and rapid, it may be necessary to consider IOI with BIG as an alternative option in case IVI is difficult or impossible in adult and pediatric patients.

Intraosseous vascular access: A review

Intraosseous cannulation is an increasingly common means of achieving vascular access for the administration of fluids and medications during the emergent resuscitation of both paediatric and adult patients. Improved tools and techniques for intraosseous vascular access have recently been developed, enabling the healthcare provider to choose from a wide range of devices and insertion sites. Despite its increasing popularity within the adult population, and decades of use in the paediatric population, questions remain regarding the safety and efficacy of intraosseous infusion. Although various potential complications of intraosseous cannulation have been theorized, few serious complications have been reported. This article aims to provide a review of the current literature on intraosseous vascular access, including discussion on the various intraosseous devices currently available in the market, the advantages and disadvantages of intraosseous access compared to conventional vascular access methods, complications of intraosseous cannulation and current recommendations on the use of this approach.

Efficacy of the EZ-IO needle driver for out-of-hospital intraosseous access--a preliminary, observational, multicenter study

Background

Intraosseous (IO) access represents a reliable alternative to intravenous vascular access and is explicitly recommended in the current guidelines of the European Resuscitation Council when intravenous access is difficult or impossible. We therefore aimed to study the efficacy of the intraosseous needle driver EZ-IO^® in the prehospital setting.

Methods

During a 24-month period, all cases of prehospital IO access using the EZ-IO^® needle driver within three operational areas of emergency medical services were prospectively recorded by a standardized questionnaire that needed to be filled out by the rescuer immediately after the mission and sent to the primary investigator. We determined the rate of successful insertion of the IO needle, the time required, immediate procedure-related complications, the level of previous experience with IO access, and operator's subjective satisfaction with the device.

Results

77 IO needle insertions were performed in 69 adults and five infants and children by emergency physicians (n = 72 applications) and paramedics (n = 5 applications). Needle placement was successful at the first attempt in all but 2 adults (one patient with unrecognized total knee arthroplasty, one case of needle obstruction after placement). The majority of users (92%) were relative novices with less than five previous IO needle placements. Of 22 responsive patients, 18 reported pain upon fluid administration via the needle. The rescuers' subjective rating regarding handling of the device and ease of needle insertion, as described by means of an analogue scale (0 = entirely unsatisfied, 10 = most satisfied), provided a median score of 10 (range 1-10).

Conclusions

The EZ-IO^® needle driver was an efficient alternative to establish immediate out-of-hospital vascular access. However, significant pain upon intramedullary infusion was observed in the majority of responsive patients.

Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients

OBJECTIVE

Studies on humeral placement of the EZ-IO (Vidacare, Shavano Park, TX, USA) have shown mixed results. We performed a study to determine the first-attempt success rate at humeral placement of the EZ-IO by paramedics among prehospital adult cardiac arrest patients.

METHODS

A retrospective cohort analysis of data prospectively collected over a 9-month period. Data are a subset extracted from a prehospital cardiac arrest study. The cohort consisted of adult cardiac arrest patients in whom the EZ-IO placement was attempted in the humerus by paramedics. Choice of vascular access was at the discretion of the paramedic; options included tibial or humeral EZ-IO and intravenous. Primary outcome is the percentage of successful placements (stable, flow, without extravasation) on first attempt. Secondary outcomes are overall successful placement, complications, and reason for failure. Data were collected during a post-cardiac arrest interview.

RESULTS

Humeral intraosseous (IO) access was attempted in 61% (n = 247) of 405 cardiac arrests evaluated with mean age of 63 (±16) years, 58% male. First-attempt successful placement was 91%. Successful placement was 94%, considering the second attempts. In the unsuccessful attempts, 2% reported obesity as the cause, 1% reported stable placement without flow, and 2% reported undocumented causes for failure. There were also 2% reports of successful placement with subsequent dislodgement.

CONCLUSIONS

The results of this study suggest a high degree of paramedic proficiency in establishment of IO access in the proximal humerus of the out-of-hospital cardiac arrest. Few complications suggest that proximal humeral IO access is a reliable method for vascular access in this patient population.

Intraosseous devices for intravascular access in adult trauma patients

Three intraosseous devices have been approved by the Food and Drug Administration for use in adult trauma patients when intravenous access cannot be obtained. Sites of insertion are the sternum (FAST1), proximal tibia and humerus (Big Injection Gun), and proximal and distal tibia and humerus (EZ-IO). Insertion generally requires less than 1 minute, and flow rates up to 125 mL/min can be achieved. The devices are used for emergency resuscitation and should be removed within 24 hours of insertion or as soon as practical after peripheral or central intravenous access has been achieved. Contraindications include fractures or other trauma at the insertion site, prosthetic joints near the site, previous attempts to insert an intra osseous device at the same site, osteoporosis or other bone abnormalities, infections at the proposed site, and inability to identify pertinent insertion landmarks. Primary complications are extravasation of medications and fluids into the soft tissue, fractures caused by the insertion, and osteomyelitis.

Tibial subacute osteomyelitis with intraosseous abscess: an unusual complication of intraosseous infusion

Intravenous (IV) access is a critical step in patient care, especially in the emergency and/or trauma setting. Recently, intraosseous (IO) infusion has re-emerged as a recommended alternative to central venous access in both the pediatric and the adult patient. We present the case of an older adult male patient several months after emergency tibial IO infusion, now with left shin pain, and the MRI and culture findings diagnostic of subacute osteomyelitis with IO abscess, an unusual complication of IO infusion.

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 2.0min+/-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 2.2min+/-1.0 for the BIG versus 1.8min+/-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.

Emergency intraosseous access in a helicopter emergency medical service: a retrospective study

BACKGROUND

Intraosseous access (IO) is a method for providing vascular access in out-of-hospital resuscitation of critically ill and injured patients when traditional intravenous access is difficult or impossible. Different intraosseous techniques have been used by our Helicopter Emergency Medical Services (HEMS) since 2003. Few articles document IO use by HEMS physicians. The aim of this study was to evaluate the use of intraosseous access in pre-hospital emergency situations handled by our HEMS.

METHODS

We reviewed all medical records from the period May 2003 to April 2010, and compared three different techniques: Bone Injection Gun (B.I.G® - Waismed), manual bone marrow aspiration needle (Inter V - Medical Device Technologies) and EZ-IO® (Vidacare), used on both adults and paediatric patients.

RESULTS

During this seven-year period, 78 insertion attempts were made on 70 patients. Overall success rates were 50% using the manual needle, 55% using the Bone Injection Gun, and 96% using the EZ-IO®. Rates of success on first attempt were significantly higher using the EZ-IO® compared to the manual needle/Bone Injection Gun (p < 0.01/p < 0.001). Fifteen failures were due to insertion-related problems (19.2%), with four technical problems (5.1%) and three extravasations (3.8%) being the most frequent causes. Intraosseous access was primarily used in connection with 53 patients in cardiac arrest (75.7%), including traumatic arrest, drowning and SIDS. Other diagnoses were seven patients with multi-trauma (10.0%), five with seizures/epilepsy (7.1%), three with respiratory failure (4.3%) and two others (2.9%). Nearly one third of all insertions (n = 22) were made in patients younger than two years. No cases of osteomyelitis or other serious complications were documented on the follow-up.

CONCLUSIONS

Newer intraosseous techniques may enable faster and more reliable vascular access, and this can lower the threshold for intraosseous access on both adult and paediatric patients in critical situations. We believe that all emergency services that handle critically ill or injured paediatric and adult patients should be familiar with intraosseous techniques.

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.

Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation

INTRODUCTION

Intraosseous needle insertion for vascular access is a standard procedure used in paediatric resuscitation. The introduction of newer automated intraosseous devices has recently expanded its role to include resuscitation in patients of all ages. Managing resuscitation can be challenging and a misplaced intraosseous needle may confound effective resuscitation. Colour Doppler ultrasound has been recently proposed as a method to confirm intraosseous needle placement. The ability to rapidly determine the correct position of an intraosseous needle during resuscitation would allow the delivery of medication or fluid infusion into the vascular space to be verified, thus optimizing resuscitation. Furthermore, complications from intraosseous infusion extravasating into soft tissues, such as compartment syndrome, or tissue necrosis can be avoided.

METHODS

We describe the point-of-care sonographic technique and colour Doppler ultrasound findings of intraosseous needle confirmation in a case series of critically ill patients requiring resuscitation, highlighting the utility of this sonographic application.

RESULTS

Colour Doppler ultrasound detected extraosseous flow in incorrectly positioned intraosseous needles, and intraosseous flow in correctly positioned intraosseous needles in six critically ill patients requiring resuscitation.

CONCLUSIONS

The use of point-of-care colour Doppler ultrasound to determine the location of both manually inserted or automated placement of intraosseous access during resuscitation is feasible, can be rapidly performed, may verify delivery of resuscitative medications or infusions, and avoid complications from extravasation.