Resuscitation and Evaluation With Intraosseous Access: A Review of the Literature in Trauma and Non-Trauma Patients

According to trauma resuscitation guidelines, intraosseous (IO) access is appropriate when failure to gain intravenous (IV) access is present in trauma, burn, shock, or resuscitation settings for adults or when two failed attempts have been made in the resuscitation of a pediatric patient. However, their effectiveness and use have been debated due to concerns on flow rates, extravasation, compartment syndrome, and osteomyelitis. The objective of this review is to examine the current literature regarding intraosseous access in trauma resuscitation, focusing on interventions and complication rates.

Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future

The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.

Sex differences in appropriate insertion depth for intraosseous access in adults: An exploratory radiologic single-center study

BACKGROUND

Intraosseous access is a recommended alternative to venous access in emergencies. For its application, knowledge of the correct insertion depth is indispensable. We aimed to determine sex-specific differences on the appropriate insertion depth for intraosseous access in adults at the insertion sites most frequently used, namely the proximal and distal tibia and the proximal humerus.

METHODS

In this exploratory retrospective study, we measured thickness of soft tissue cover, cortex and cancellous bone along the puncture line on magnetic resonance images or computed tomography scans. Inclusion criteria were both sexes, 18-90 years of age and appropriate image quality. Primary outcome was the appropriate insertion depth to reach the cancellous bone for each sex. This was defined as the corridor between (i) the sum of the soft tissue cover and the cortex and (ii) the sum of (i) plus the diameter of the cancellous bone. Secondary outcomes were the differences in thickness of each layer between sexes.

RESULTS

In 179 females and males, the appropriate insertion depth was 32.5-45.5 mm and 20.5-42.0 mm in the proximal tibia, 14.5-30.5 mm and 16.5-34.5 mm in the distal tibia, and 27.5-52.5 mm and 26.0-56.5 mm in the proximal humerus. Although females had a thicker soft tissue cover (+6.8 mm [95% CI 3.7-10.1], p < 0.01) in the proximal tibia, extrapolation by correlation analysis showed no clinically relevant difference between the sexes.

CONCLUSION

In adults, there are no sex-specific differences in the appropriate insertion depth for intraosseous access in the proximal or distal tibia or in the proximal humerus.

Use of point of care ultrasound (POCUS) by intensive care paramedics to achieve peripheral intravenous access in patients predicted to be difficult: An out-of-hospital pilot study

INTRODUCTION

Intravenous cannulation is a common procedure for paramedics. Difficulty is often encountered and may result in escalation of care to an intensive care paramedic (ICP). Ultrasound-guided peripheral intravenous access (USGPIVA) is used in-hospital as an alternative approach. Historically limited to physicians, it is increasingly embraced by non-physicians, with point of care ultrasound (POCUS) devices more affordable, portable, and suited to the out of hospital environment.

OBJECTIVE

To explore the utility of ICP-performed USGPIVA for patients who are predicted to be difficult according to a difficult intravenous access scoring tool.

METHODS

This was a prospective observational pilot study of ICPs who used the adult difficult intravenous access (A-DIVA) scale to predict difficulty and perform USGPIVA using a contemporary POCUS device.

RESULTS

For the 32 patients enroled, the overall success rate was 50% of which 87% were successful on the first attempt. Mean A-DIVA score was 4.1/5, and paradoxically, success improved with A-DIVA-predicted difficulty.

CONCLUSION

ICPs can perform USGPIVA with moderate success. The A-DIVA score could be useful for paramedics to predict difficult cannulation. Future research should focus on increasing exposure, training time and enhancing feedback to paramedics performing USGPIVA.

Intraosseous Regional Administration of Antibiotic Prophylaxis for Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA).

METHODS

PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics.

RESULTS

All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 μg/g [fat] and 49.3 μg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 μg/g [fat] and 5.2 μg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively.

CONCLUSION

Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit.

Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis

BACKGROUND

During medical emergencies, intraosseous (IO) access and intravenous (IV) access are methods of administering therapies and medications to patients. Treating patients in emergency medical situations is a highly time sensitive practice; however, research into the optimal access method is limited and existing systematic reviews have only considered out-of-hospital cardiac arrest (OHCA) patients. We focused on severe trauma patients and conducted a systematic review to evaluate the efficacy and efficiency of intraosseous (IO) access compared to intravenous (IV) access for trauma resuscitation in prehospital care.

MATERIALS AND METHOD

PubMed, Web of Science, Cochrane Library, EMBASE, ScienceDirect, banque de données en santé publique and CNKI databases were searched for articles published between January 1, 2000, and January 31, 2023. Adult trauma patients were included, regardless of race, nationality, and region. OHCA patients and other types of patients were excluded. The experimental and control groups received IO and IV access, respectively, in the pre-hospital and emergency departments for salvage. The primary outcome was success rate on first attempt, which was defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Secondary outcomes included mean time to resuscitation, mean procedure time, and complications.

RESULTS

Three reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; meta-analyses were then performed using Review Manager (Version 5.4; Cochrane, Oxford, UK). The success rate on first attempt was significant higher for IO access than for IV access (RR = 1.46, 95% CI [1.16, 1.85], P = 0.001). The mean procedure time was significantly reduced (MD = - 5.67, 95% CI [- 9.26, - 2.07], P = 0.002). There was no significant difference in mean time to resuscitation (MD = - 1.00, 95% CI [- 3.18, 1.17], P = 0.37) and complications (RR = 1.22, 95% CI [0.14, 10.62], P = 0.86) between the IO and IV groups.

CONCLUSION

The success rate on first attempt of IO access was much higher than that of IV access for trauma patients, and the mean procedure time of IO access was significantly less when compared to IV access. Therefore, IO access should be suggested as an urgent vascular access for hypotensive trauma patients, especially those who are under severe shock.

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.

Intra-osseous cerebrospinal fluid shunts-Overview of past and present clinical and experimental evidence

In the history of hydrocephalus treatment, a variety of diversion sites have been explored to ensure an adequate alternative when the peritoneum was not a feasible option. An interesting choice was the elimination of excessive cerebrospinal fluid (CSF) in the skeletal system. The purpose of this review was to evaluate all shunting systems that have been implemented in bone structures and to determine their therapeutic potential. All articles pertaining to bone derivations were selected from PubMed, Medline, EBSCO and Scopus, using relevant search terms. The search revealed 6 types of osseous shunts that have been used throughout history: vertebral, diploic, ventriculomastoid, ventriculoiliac, ventriculosternal and ventriculohumeral. Some of them are purely of historical significance, but data from more recent clinical and experimental studies have rendered this type of receptacle a potential site for diverting CSF. Having knowledge of all the alternatives used in cases of refractory hydrocephalus is vital for choosing the appropriate surgical intervention.

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.

Intraosseous vascular access using the EZ-IO can be safely maintained in the adult proximal humerus and proximal tibia for up to 48 h: Report of a clinical study

BACKGROUND

Historically, intraosseous (IO) vascular access devices cleared to market by the US FDA have been restricted to 24-h use. An observational study was conducted to determine the safety of IO access for a period up to 48 h in adult volunteers.

METHODS

A 2-arm randomized, stratified, parallel assignment, prospective interventional study was conducted at ICON Early Phase Services in San Antonio, Texas, United States. Study subjects were adult volunteers who were healthy or with a history of mild to moderate renal disease and/or controlled diabetes. Subjects were randomized to receive IO access (Arrow EZ-IO Vascular Access System, Teleflex Medical Incorporated, Morrisville, NC, USA) in the proximal humerus or the proximal tibia and maintain the indwelling catheter for 48 h. Subjects were monitored for the entire dwell time. A culture specimen was drawn from the indwelling catheter tip before removal and insertion site x-rays were taken.

RESULTS

121 subjects were randomized: 79 healthy, 39 with diabetes, and three with diabetes and renal insufficiency. The mean catheter dwell time was 48.0 ± 0.2 h. Overall first attempt success rate was 98.4%. Infusion pain was the most commonly reported adverse event. There were no serious complications or unanticipated adverse events.

CONCLUSIONS

This is the first known study examining the safety of IO access over a 48-h dwell time. The study corroborates the literature findings, demonstrates device safety, and provides evidence supporting the extended indication for a dwell time to 48 h in adult patients. IO placement and infusion best practices/guidelines were confirmed or established.

Intraosseous access in the resuscitation of trauma patients: a literature review

PURPOSE

Intraosseous (IO) catheters continue to be recommended in trauma resuscitation. Their utility has recently been debated due to concerns regarding inadequate flow rates during blood transfusion, and the potential for haemolysis. The objective of this review was to examine the evidence for intraosseous catheters in trauma resuscitation, and to highlight areas for future research.

METHODS

A PubMed and Embase search for articles published from January 1990 to August 2018 using the terms ("intra-osseous access" or "intraosseous access" or "IO access") AND trauma was performed. Original articles describing the use of an IO catheter in the resuscitation of one or more trauma patients were eligible. Animal, cadaveric studies and those involving healthy volunteers were excluded.

RESULTS

Nine studies, comprising of 1218 trauma patients and 1432 device insertions, were included. The insertion success rate was 95% and the incidence of complications 0.9%. Flow-rate data and evidence of haemolysis were poorly reported.

CONCLUSION

Intraosseous catheters have high insertion success rates and a low incidence of complications in trauma patients. Existing evidence suggests that IO transfusion is not associated with haemolysis, however, further studies in humans are needed. There is a paucity of flow rate data for blood transfusion via IO catheters in this population, although much anecdotal evidence advocating their use exists.

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest

BACKGROUND

Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known.

METHODS

In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration.

RESULTS

Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06-1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5-9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02-1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7-8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66-1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74-1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant.

CONCLUSIONS

We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.

Emergency Physicians at War

Operation Enduring Freedom (OEF-A) in Afghanistan and Operation Iraqi Freedom (OIF) represent the first major, sustained wars in which emergency physicians (EPs) fully participated as an integrated part of the military’s health system. EPs proved invaluable in the deployments, and they frequently used the full spectrum of trauma and medical care skills. The roles EPs served expanded over the years of the conflicts and demonstrated the unique skill set of emergency medicine (EM) training. EPs supported elite special operations units, served in medical command positions, and developed and staffed flying intensive care units. EPs have brought their combat experience home to civilian practice. This narrative review summarizes the history, contributions, and lessons learned by EPs during OEF-A/OIF and describes changes to daily clinical practice of EM derived from the combat environment.

Design, Development, and Validation of an Intra-Osseous Needle Placement Guide

Intra-osseous (IO) needles are an easy and reliable alternative to intravenous (IV) access in the prehospital and emergency settings for treating patients in shock. The advantage of utilizing an IO is that secure, noncollapsible peripheral venous access can be obtained rapidly in critically ill patients. Placement of IO needles in the proximal tibia, humerus, or sternum, however, requires knowledge of human anatomy and the requisite skill to position, align, and place the device. In the developing world, this is not always available, and in the chaos of an in-hospital code, prehospital trauma, or a mass-casualty incident, even trained providers can have trouble correctly placing IV or IO needles. The Tib-Finder is an intuitive drill guide that significantly improves efficiency with which IO can be placed in the proximal tibia. Here, we present the conceptualization, design, and creation of an alpha-prototype Tib-Finder drill guide in less than 90 days; initial validation was achieved through analysis of anthropometric measurements of human skeletons, and usability studies were performed using untrained volunteers and mannequins. The Tib-Finder is intended to provide first responders and medical personnel, in the first world and the developing world, a way to accurately and repeatably locate the proximal tibia and achieve safe, rapid intravascular access in critically ill patients. Further, it eliminates the need for direct contact between patients and caregivers and improves the ease-of-use of IO devices by first responders and healthcare providers.

Comparison of tranexamic acid plasma concentrations when administered via intraosseous and intravenous routes

INTRODUCTION

There is a lack of information regarding intraosseous (IO) administration of tranexamic acid (TXA). Our hypothesis was that a single bolus IO injection of TXA will have a similar pharmacokinetic profile to TXA administered at the same dose IV.

METHODS

Sixteen male Landrace cross swine (mean body weight 27.6±2.6kg) were divided into an IV group (n=8) and an IO group (n=8). Each animal received 30mg/kg TXA via an IV or IO catheter, respectively. Jugular blood samples were collected for pharmacokinetic analysis over a 3h period. The maximum TXA plasma concentration (C_max) and corresponding time as well as distribution half-life, elimination half-life, area under the curve, plasma clearance and volume of distribution were calculated. One- and two-way analysis of variance for repeated measures (time, group) with Tukey's and Bonferonni post hoc tests were used to compare TXA plasma concentrations within and between groups, respectively.

RESULTS

Plasma concentrations of TXA were significantly higher (p<0.0001) in the IV group during the TXA infusion. C_max occurred at 4min after initiation of the bolus in the IV group (9.36±3.20ng/μl) and at 5min after initiation of the bolus in the IO group (4.46±0.49ng/μl). Plasma concentrations were very similar from the completion of injection onwards. There were no significant differences between the two administration routes for any other pharmacokinetic variables measured.

CONCLUSION

The results of this study support pharmacokinetic bioequivalence of IO and IV administration of TXA.

The versatility of intraosseous vascular access in perioperative medicine: a case series

Intraosseous vascular access is a time-tested procedure that is reemerging in popularity. This is primarily a result of the emphasis on intraosseous access in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Advanced Cardiac Life Support. Modern intraosseous insertion devices are easy to learn and use, suggesting the possibility of use beyond the resuscitation setting. We present a case series of recent intraosseous insertions for a variety of indications by anesthesiologists at our institution to demonstrate the potential utility of this alternative access technique.

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.

Intra-articular Placement of an Intraosseous Catheter

Gaining vascular access is essential in the resuscitation of critically ill patients. Intraosseous (IO) placement is a fundamentally important alternative to intravenous (IV) access in conditions where IV access delays resuscitation or is not possible. This case report presents a previously unreported example of prehospital misplacement of an IO catheter into the intra-articular space of the knee joint. This report serves to inform civilian and military first responders, as well as emergency medicine physicians, of intra-articular IO line placement as a potential complication of IO vascular access. Infusion of large amounts of fluid into the joint space could damage the joint and be catastrophic to a patient who needs immediate IV fluids or medications. In addition, intra-articular IO placement could result in septic arthritis of the knee.

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.

Evaluation of the sternal intraosseous route as alternative emergency vascular access for the dental office: a manikin and cadaver model pilot study

OBJECTIVE

To evaluate 2 sternal intraosseous access devices as alternatives to emergency intravenous access for dentists, using a manikin and a cadaver model.

STUDY DESIGN

A group of 37 students performed a sternal intraosseous access on a manikin using a Vidacare kit including a puncture template and a prepuncture skin incision. Five months later, 9 of the students used the Vidacare and 8 used an Illinois needle (without template and incision) on adult human cadavers. India ink was injected as a tracer.

RESULTS

Shorter times were recorded on cadavers compared with manikins in both systems. One Vidacare puncture ended subcutaneously. Two Illinois needle punctures perforated the sternum, one with intense mediastinal ink traces. Vidacare punctures took longer compared with Illinois needle punctures (medians, 32 vs 12 seconds; P = .0002).

CONCLUSIONS

Template use to identify the sternal puncture position, combined with additional prepuncture skin incision, may be more efficient and less predisposed to severe complications for dentists' emergency use.