Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study

Factors associated with failure of intraosseous access in prehospital trauma treatment by military medical personnel

INTRODUCTION

Intraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding their real-world utilisation in prehospital settings. Therefore, this study aims to evaluate the success rates of intraosseous access in a prehospital military context and identify factors associated with failure.

METHODS

Using the Israel Defense Forces (IDF) Trauma Registry, we retrospectively collected data from 2010 to 2023. The primary outcome was the first pass success rate of intraosseous access, and logistic regression models were applied to identify variables associated with first pass failure.

RESULTS

The study included 172 trauma patients who underwent attempted intraosseous access with 46.5% cases which were classified as military events. The median age was 22 years, and 17.3% were paediatric patients. First pass success was achieved in 67.4% of cases, with a cumulative success rate of 80.8% after multiple attempts. Moreover, significant differences were noted when examining the success rate of the three intraosseous devices used by the IDF teams, with the highest success rate being documented for the NIO Adult versus the EZ-IO or the BIG (81.4%; 76.7%; 62.4%). However, logistic regression analysis revealed that the number of PIV access attempts was the only variable significantly associated with decreased odds of achieving first pass intraosseous access.

CONCLUSION

These findings suggest that intraosseous devices are a viable alternative for establishing vascular access in prehospital military settings. However, success rates were slightly lower than previous reports, potentially due to the severity of injuries in the study cohort. Our analyses revealed a higher number of PIV access attempts correlated with reduced first pass intraosseous success, possibly stemming from caregiver proficiency in obtaining vascular access. Further research is needed to explore additional factors affecting intraosseous access success rates.

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.

Prehospital Trauma Care

Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.

Effects of Endotracheal Epinephrine on Pharmacokinetics and Survival in a Swine Pediatric Cardiac Arrest Model

OBJECTIVES

The aim of this study was to compare the endotracheal tube (ET) and intravenous (IV) administration of epinephrine relative to concentration maximum, time to maximum concentration, mean concentration over time (MC), area under the curve, odds, and time to return of spontaneous circulation (ROSC) in a normovolemic pediatric cardiac arrest model.

METHODS

Male swine weighing 24-37 kg were assigned to 4 groups: ET (n = 8), IV (n = 7), cardiopulmonary resuscitation (CPR) + defibrillation (CPR + Defib) (n = 5), and CPR only (n = 3). Swine were placed arrest for 2 minutes, and then CPR was initiated for 2 minutes. Epinephrine (0.1 mg/kg) for the ET group or 0.01 mg/kg for the IV was administered every 4 minutes or until ROSC. Defibrillation started at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC for all groups except the CPR-only group. Blood samples were collected over a period of 5 minutes.

RESULTS

The MC of plasma epinephrine for the IV group was significantly higher at the 30- and 60-second time points (P = 0.001). The ET group had a significantly higher MC of epinephrine at the 180- and 240-second time points (P < 0.05). The concentration maximum of plasma epinephrine was significantly lower for the ET group (195 ± 32 ng/mL) than for the IV group (428 ± 38 ng/mL) (P = 0.01). The time to maximum concentration was significantly longer for the ET group (145 ± 26 seconds) than for the IV group (42 ± 16 seconds) (P = 0.01). No significant difference existed in area under the curve between the 2 groups (P = 0.62). The odds of ROSC were 7.7 times greater for the ET versus IV group. Time to ROSC was not significantly different among the IV, ET, and CPR + Defib groups (P = 0.31).

CONCLUSIONS

Based on the results of this study, the ET route of administration should be considered a first-line intervention.

Mono- and bi-plane sonographic approach for difficult accesses in the emergency department - A randomized trial

BACKGROUND

The insertion of peripheral intravenous (PIV) catheters is one of the most performed invasive procedures in acute healthcare settings. However, peripheral difficult vascular access (PDVA) is not uncommon and can lead to delays in administering essential medications. Ultrasound (US) has emerged as a valuable tool for facilitating PIV cannulation. Advancements in technology have introduced a technique known as bi-plane imaging, allowing the simultaneous display of both longitudinal and transverse views of vessels. We aimed to investigate whether the utilization of bi-plane imaging, as opposed to the single-plane approach, would yield superior results for PDVA in the emergency department (ED).

METHODS

This study was a single-center randomized controlled trial. We included adult patients admitted to the ED who required PIV cannulation. Patients were randomly assigned to undergo cannulation using either the mono-plane or bi-plane approach, both performed by skilled providers. The primary outcome of the study was to compare the first attempt success rates between the two techniques.

RESULTS

A total of 442 patients were enrolled, with 221 undergoing cannulation attempts using the mono-plane approach. Successful placement of a functioning PIV catheter was achieved in a single attempt for 313 out of 442 patients (70.8%). There was no significant difference in the success rates between the two study groups: 68.3% in the mono-plane group and 73.3% in the bi-plane group (p = 0.395). The median time required for a successful attempt differed between the groups, with 45 s (range 18-600) in the mono-plane group and 35 s (range 20-600) in the bi-plane group (p = 0.03).

CONCLUSIONS

Our study confirms that US is a highly effective tool for facilitating PIV cannulation in patients with PDVA presenting to the ED. However, our investigation into the use of bi-plane imaging did not reveal a significant improvement when compared to mono-plane imaging.

Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report

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.

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest

Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.

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.

Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study)

BACKGROUND

Over the past decades, international guidelines for cardiopulmonary resuscitation (CPR) have changed the recommendation for alternative routes for drug administration. Until now, evidence for the substantial superiority of one route with respect to treatment outcome after CPR has been lacking. The present study compares the effects of intravenous (IV), intraosseous (IO) and endotracheal (ET) adrenaline application during CPR in out-of-hospital cardiac arrest (OHCA) on clinical outcomes within the database of the German Resuscitation Registry (GRR).

METHODS

This registry analysis was based on the GRR cohort of 212,228 OHCA patients between 1989 and 2020. Inclusion criteria were: OHCA, application of adrenaline, and out-of-hospital CPR. Excluded from the study were patients younger than 18 years, those who had trauma or bleeding as suspected causes of cardiac arrest, and incomplete data sets. The clinical endpoint was hospital discharge with good neurological outcome [cerebral performance category (CPC) 1/2]. Four routes of adrenaline administration were compared: IV, IO, IO + IV, ET + IV. Group comparisons were done using matched-pair analysis and binary logistic regression.

RESULTS

In matched-pair group comparisons of the primary clinical outcome hospital discharge with CPC 1/2, the IV group (n = 2416) showed better results compared to IO (n = 1208), [odds ratio (OR): 2.43, 95% confidence interval (CI): 1.54-3.84, p < 0.01] and when comparing IV (n = 8706) to IO + IV (n = 4353), [OR: 1.33, 95% CI: 1.12-1.59, p < 0.01]. In contrast, no significant difference was found between IV (n = 532) and ET + IV (n = 266), [OR: 1.26, 95% CI: 0.55-2.90, p = 0.59]. Concurrently, binary logistic regression yielded a highly significant effect of vascular access type (χ² = 67.744(3), p < 0.001) on hospital discharge with CPC1/2, with negative effects for IO (regression coefficient (r.c.) = - 0.766, p = 0.001) and IO + IV (r.c. = - 0.201, p = 0,028) and no significant effect for ET + IV (r.c. = 0.117, p = 0.770) compared to IV.

CONCLUSIONS

The GRR data, collected over a period of 31 years, seem to emphasize the relevance of an IV access during out-of-hospital CPR, in the event that adrenaline had to be administered. IO administration of adrenaline might be less effective. ET application, though removed in 2010 from international guidelines, could gain importance as an alternative route again.

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.

Management of penetrating chest trauma in the context of major trauma networks

Major trauma networks reduce mortality in critically injured patients. Trauma patients should be appropriately triaged straight from the scene of injury, avoiding secondary transfer from a trauma unit. Selection criteria in regionally agreed triage tools are designed to identify which patients should be taken directly to the major trauma centre. Patients with life-threatening injuries still arrive at 'trauma units' in circumstances such as self-presentation, under triage, physiological instability or long journey time to the major trauma centre. This article presents a theoretical case of a haemodynamically unstable patient with penetrating injuries, and discusses the management of chest trauma, including diagnosis of life-threatening injuries, resuscitation strategies and definitive surgical management. Secondary transfer to the major trauma centre should be considered after instituting the minimal life-saving interventions. What constitutes a life-saving intervention requires an individual dynamic risk assessment and an understanding of major trauma networks.

Physician preferences associated with powered intraosseous access systems: Safety features, reliability, and ease of use

Objective

This study evaluated physician preferences and values related to the most commonly used (traditional) powered intraosseous (IO) system and a novel powered IO system featuring a passive safety needle, battery life indicator, and snap‐securement/skin attachment.

Methods

Emergency physicians participated in an IO simulation using both the traditional and novel IO systems. Participants completed a 27‐item postsimulation questionnaire to state their preferences toward each IO system and values related to the novel IO system features using a multiple choice, 11‐point value ranking scale (0 = no value, 10 = extremely valuable) and free‐text answer questions.

Results

Among the 22 study participants, 90.9% (95% confidence interval [CI]: 70.8%, 98.9%) preferred the novel IO system; top reasons for this preference were the novel IO system's passive safety needle and snap‐securement/skin attachment. Participants who preferred the traditional IO system (9.1%) noted its ease of use and familiarity. Many physicians preferred the novel IO system's needle (81.8%; 95% CI: 59.7%, 94.8%), powered driver (77.3%; 95% CI: 54.6%, 92.2%), and snap‐securement/skin attachment (100%; 95% CI: 84.6%, 100%) compared with the traditional IO system. Safety and ease of use were the most common preference explanations. Of the participants, 100% provided a value score ≥7 for the novel IO system's passive safety needle (mean score, 9.45), whereas fewer participants (59.1%) gave a value score ≥7 for the multilight battery life indicator (mean score, 6.68).

Conclusion

This study demonstrates that emergency physicians prefer and value a novel IO system with features that enhance safety and ease of use. These results provide insight into important factors related to IO systems for emergency physicians.

[Use of the intraosseous infusion device in the resuscitation ambulances of the Paris fire brigade]

In the Paris Fire Brigade, in the context of cardiac arrest, the nurses have the greatest reported experience of intraosseous infusion. The adverse events reported are rare, given that the procedure is performed on patients in absolute emergency. All these elements are in favour of discussing a redefinition of the practice of intraosseous infusion by nurses in the specific context of immediate life-saving emergencies.

Point-of-Care Ultrasound to Identify Landmarks of the Proximal Humerus: Potential Use for Intraosseous Vascular Access

OBJECTIVES

The inability to identify landmarks is an absolute contraindication for intraosseous access. The feasibility of landmark identification using ultrasound (US) has been demonstrated on human cadavers. We aimed to study the feasibility of point-of-care US in identifying proximal humerus landmarks in living human patients.

METHODS

This was a prospective cohort study conducted from May 3 to June 7, 2017, after approval from the Institutional Review Board at the Cleveland Clinic. Sixty upper extremities of 30 consenting participants across 3 distinct body mass index (BMI) groups (normal, obese, and morbidly obese) were alternately examined with a 12 L-RS linear US transducer (GE Healthcare, Chicago, IL) by 2 investigators. Six anatomic landmarks were identified: the humeral shaft, the surgical neck of the humerus, the lesser tubercle, the greater tubercle, the inter tubercular sulcus, and the target site for needle insertion on the greater tubercle. Rates of successful identification of all 6 landmarks as defined by independent agreement between the investigators were reported as estimated incidence rates with 95% bootstrap confidence interval (CI) sampling at the participant level.

RESULTS

Ultrasound had an overall success rate of 0.87 (95% CI, 0.78-0.95) in identifying all 6 landmarks with slight variability among various BMI groups. After excluding the surgical neck, the overall success rate improved to 0.93 (95% CI, 0.87-0.98), with minimum variability across BMI groups and no change in the ability to identify the target site.

CONCLUSIONS

Ultrasound is reliable in identifying proximal humerus intraosseous landmarks, with reasonable accuracy across various BMI groups.

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.

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study

BACKGROUND

It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients.

METHODS

In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above.

RESULTS

A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups.

CONCLUSIONS

IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.

COVID-19 disease: Resuscitation

COVID-19 is a complex disease which has challenged the way in which care is provided. Cardiopulmonary resuscitation (CPR) is recognized as a potential aerosol-generating procedure, in consequence, a modified advanced life support approach needs to be followed. This article describes the actions for an adult in cardiac arrest with suspected of confirmed COVID-19 disease in a hospital setting.

Development, Diagnostic Sensitivity, and Prognostic Accuracy of the Adult-Difficult Venous Catheterization Scale for Emergency Departments

INTRODUCTION

Difficulty in accessing peripheral veins in emergency departments increases patients' discomfort and impedes their diagnosis. The objective of this study was to develop and test the prognostic accuracy of an easily applied scale to measure difficult venous access to peripheral veins in emergency departments, called the Adult-Difficult Venous Catheterization scale.

METHODS

This prospective observational study was conducted in adults from the hospital catchment area attending the emergency department. Using the Delphi technique, 5 experts reached a consensus regarding a 3-item scale scored from 0 to 5. Concurrent validity and predictive validity were analyzed using a numeric rating scale and the number of access attempts, respectively. Internal consistency and interobserver reliability for 3 independent observers were analyzed using Cronbach alpha and Cohen kappa, respectively.

RESULTS

In 392 participants, the concurrent and predictive validity scores pointed to positive relationships with the numeric rating scale (r = 0.82; P < 0.001) and the number of access attempts (r = 0.5; P < 0.001), respectively. The odds ratio for 1 to 2 access attempts versus more than 2 access attempts in relation to the Adult-Difficult Venous Catheterization scale score was 2.76 (95% confidence interval 1.86, 4.08; P < 0.001). Sensitivity and specificity values for the Adult-Difficult Venous Catheterization scale were good, at 93.75% and 78.99%, respectively, as were internal consistency (Cronbach alpha 0.81) and interobserver reliability (Cohen kappa 0.75).

DISCUSSION

The Adult-Difficult Venous Catheterization scale is a valid and reliable instrument for predicting difficult venous access in emergency departments.

Intraosseous Administration of Hypertonic Saline in Acute Brain-Injured Patients: A Prospective Case Series and Literature Review

BACKGROUND

Central venous catheters are often used to administer hypertonic saline (HTS) but might be associated with serious complications. Intraosseous (IO) access is an alternative method of medication and fluid delivery which is not associated with life-threatening complications and can be inserted faster than CVCs.

METHODS

A prospective case series was conducted on critically ill neurological patients that did not have central venous access, and for whom 3% HTS was indicated. Nonverbal indicators of pain were measured using the critical care pain observation tool. The pain score and serum sodium levels were collected at baseline, at 2, 6, 12, 18, and 24 hours after administration of 3% HTS using IO access. The area surrounding the IO insertion site was monitored for needle placement, extravasation, and tissue damage.

RESULTS

Five patients were enrolled. Three had an IO placed in the proximal humerus and 2 in the proximal tibia. Most patients did not have nonverbal indicators of pain during insertion and initial bolus. Serum sodium levels increased appropriately, as determined by the care providers. There were no cases of device dislodgement, extravasation, infection, soft tissue injury, or other local complications.

CONCLUSIONS

In this prospective case series, IO administration of 3% HTS was feasible, well-tolerated on the basis of nonverbal indicators of pain in the majority of patients and resulted in an appropriate rise in serum sodium levels. IO fills a niche among vascular access options for HTS, in emergent neurological situations when central venous access is not readily available or peripheral intravenous access is difficult to obtain.

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.

Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension

BACKGROUND/OBJECTIVE

Prompt treatment of acute intracranial hypertension is vital to preserving neurological function and frequently includes administration of 23.4% NaCl. However, 23.4% NaCl administration requires central venous catheterization that can delay treatment. Intraosseous catheterization is an alternative route of venous access that may result in more rapid administration of 23.4% NaCl.

METHODS

Single-center retrospective analysis of 76 consecutive patients, between January 2015 and January 2018, with clinical signs of intracranial hypertension received 23.4% NaCl through either central venous catheter or intraosseous access.

RESULTS

Intraosseous cannulation was successful on the first attempt in 97% of patients. No immediate untoward effects were seen with intraosseous cannulation. Time to treatment with 23.4% NaCl was significantly shorter in patients with intraosseous access compared to central venous catheter (p < 0.0001).

CONCLUSIONS

Intraosseous cannulation resulted in more rapid administration of 23.4% NaCl with no immediate serious complications. Further investigations to identify the clinical benefits and safety of hypertonic medication administration via intraosseous cannulation are warranted.

Intraosseous Catheter Flow Rates and Ease of Placement at Various Sites in Canine Cadavers

Objective: To compare intraosseous catheter placement difficulty, success rates, and flow rates at four different locations in canine cadavers.

Design: Prospective study.

Setting: Private referral center.

Animals: Eleven fresh canine cadavers.

Interventions: With owner consent, animals presenting for euthanasia were recruited. Animals received heparin (1,000 IU/kg IV) at least 5 min prior to euthanasia. After euthanasia, EZIO intraosseous catheters were placed into the ilial wing, proximal medial tibia, proximal lateral humerus, and distal lateral femur on one side of the animal. Time to catheter placement and catheter difficulty were scored for each placement site. Sterile saline was infused into each location simultaneously over 5 min, first via gravity then using 300 mmHg pressure. Animals were repositioned onto the contra-lateral side and the experiment repeated.

Measurements and Main Results: Placement was successful in 16/22 ilial, 18/22 tibial, and 22/22 femoral and humoral attempts. A post-hoc analysis revealed the ileum had a significantly greater difficulty score when compared to the femur and humerus (p ≤ 0.0001). The femur had a statistically significant faster placement time when compared to the ileum (p ≤ 0.05). Gravity infusion rates were statistically lower in the tibia when compared to humerus (p ≤ 0.01) and between the tibia when compared to the femur (p ≤0.001). Additionally, pressurized infusion rates were statistically lower in the tibia compared to the humerus (p ≤ 0.0001), the femur (p ≤ 0.0001), and the ileum (p ≤ 0.01).

Conclusions: The femur and humerus had high success rate for IO catheter placement and low placement time and difficulty scores. Pressurized intraosseous flow rates were highest in the humerus and femur. Contrary to human literature, success rates for catheter placement in the humerus and femur were higher than at other sites, suggesting the humerus and femur may be preferred sites for intraosseous catheter placement in the dog. Further investigation through a larger sample size is required to confirm these findings.

Ventriculo-humeral shunt: a cadaveric feasibility study with application to treating hydrocephalus

PURPOSE

Intraosseous vascular access is often used when vascular access is difficult. However, the use of this space for a receptacle for cerebrospinal fluid (CSF) diversion has been scantly considered.

MATERIALS AND METHODS

Six upper limbs of fresh frozen cadavers were used for this study. In the supine position, a small hole was drilled through the outer cortex of the proximal humerus and into the medullary cavity. A 16-gauge needle was placed into the hole in the humerus and 150 cc of saline infused. Next, the adjacent axillary vein and tributaries were dissected to observe dilation or the presence of the blue-colored saline. For part two of the study, shunt tubing was passed subcutaneously from a supraclavicular incision to the hole made in the humerus. Range of motion of the shoulder was then performed.

RESULTS

On all sides, all 150 cc of fluid was easily infused into the humerus. No specimen was found to have leakage from the drill hole site or into the extravascular soft tissues. With dissection of the axillary vein and its tributaries, all sides were found to have engorgement of these vessels. No tension was placed on the distal shunt tubing with full range of motion of the shoulder.

CONCLUSION

Based on our study, the humerus is another option available to the neurosurgeon for CSF diversion.

Risk factors for a difficult intravenous access: A multicentre study comparing nurses' beliefs to evidence

AIMS AND OBJECTIVES

To summarise the evidence about patient-related risk factors for difficult intravenous access in adults, and at identifying nurses' beliefs and their consistency with evidence.

BACKGROUND

Peripheral intravenous cannulation is a common procedure for nurses, but rates of failure at first attempt of peripheral intravenous cannulation range 10%-40%. Nurses' beliefs about difficult intravenous access factors might influence their clinical practice more than current evidence.

DESIGN

The study included a literature review of the evidence on patient-related risk factors for difficult intravenous access, the development of an instrument to investigate nurses' beliefs about this topic and a cross-sectional multicentre survey on clinical nurses.

METHODS

The quality of the studies included was evaluated through the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A synthesis of evidence for each risk factor was produced. A survey instrument was developed including 26 risk factors, which were then rated by nurses as perceived predictors of difficult intravenous access. The STROBE guidelines for study reporting were followed.

RESULTS

Four hundred and fifty clinical nurses working in four hospitals in Italy were surveyed. Nurses' beliefs were in line with evidence in considering body mass index, drug abuse, lymphadenectomy and chemotherapy as difficult intravenous access factors. Beliefs about difficult intravenous access factors were influenced by nurses' work experience and frequency of peripheral intravenous cannulation. Nurses also identified as risk factors for difficult intravenous access oedema, thrombophlebitis, hypovolaemia, skin lesions and irritant therapies, which have been minimally investigated by research.

CONCLUSIONS

An overall congruence between nurses' beliefs and evidence about risk factors for difficult intravenous access was found. With their expertise, nurses may fill the knowledge gap of clinical evidence and open new paths for clinically meaningful research.

RELEVANCE TO CLINICAL PRACTICE

Nurses' beliefs about difficult intravenous access factors can be influenced by their work experience and clinical setting. Integrating nurses' beliefs with scientific evidence can increase the quality of care.

Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation

BACKGROUND

Intraosseous (IO) vascular access is increasingly used as an emergency tool for achieving access to the systemic circulation in critically ill patients. The role of IO transfusion of blood in damage control resuscitation is however questionable due to possible inadequate flow rate and hemolysis. Some experts claim that IO transfusion is contraindicated. In this study, we have challenged this statement by looking at flow rates of autologous fresh whole blood reinfusion and hemolysis using two of the commonly used Food and Drug Administration-approved and Conformité Européenne (CE)-marked sternal needles. Additionally, the success rate of sternal access between the two devices is evaluated.

METHODS

Volunteer professional military personnel, were enrolled prospectively in a nonrandomized observational study design. We collected 450 mL of autologous whole blood from each participant. Participants were divided into the following three groups of 10: Tactically Advanced Lifesaving IO Needle (T.A.L.O.N.) IO, FAST1 IO, and intravenous group. The reinfusion was done by gravity only. Blood sampling was performed before blood collection and 30 minutes after reinfusion. Investigation of hemolysis was performed by measurements of haptoglobin and lactate dehydrogenase. Success rate was evaluated by correct aspiration of bone marrow.

RESULTS

Median reinfusion rate was 46.2 mL/min in the FAST1 group, 32.4 mL/min in the T.A.L.O.N. group, and 74.1 mL/min in the intravenous group. Blood samples from all participants were within normal ranges. There was no statistically significant difference in haptoglobin and lactate dehydrogenase between the groups. In the FAST1 group, 1 (9%) of 11 procedures failed. In the T.A.L.O.N. group, 4 (29%) of 14 procedures failed.

CONCLUSION

Although preferable, achieving peripheral venous access in the bleeding patient is a major problem. Our findings suggest that fresh whole-blood transfusion through the IO route is safe, reliable, and provide sufficient flow for resuscitation.

LEVEL OF EVIDENCE

Therapeutic/Care management study, level III.

Post-mortem computed tomography improves completeness of the trauma registry: a single institution experience

PURPOSE

To describe our institutional experience with post-mortem computed tomography (PMCT) and its impact on decedent injury severity score (ISS) and to assess the adequacy of emergently placed support medical devices.

METHODS

Over a 5-year period, patients who died at or soon after arrival and have physical exam findings inconsistent with death were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. ISS was calculated with and without the PMCT findings. PMCT results were compared to autopsy findings, if performed. The location of support medical devices was documented.

RESULTS

A total of 38 decedents underwent PMCT, including 53.1% males and a mean age of 42.0 years. Pre-PMCT ISS based on physical exam findings alone was 5.2 (range 0-25), including 16 with ISS = 0. Post-PMCT ISS using the additional imaging data was 50.3 (range 21-75), including 15 with ISS = 50 or greater. Nearly half (47.4%) had at least one support medical device that was either malpositioned or suboptimally positioned, including 26.3% with malpositioned airway devices, 10.3% with malpositioned intra-osseous catheters, and 100% with malpositioned decompressive needle thoracotomies.

CONCLUSIONS

PMCT adds value in identifying injuries that otherwise may have gone undetected in lieu of a formal autopsy, thus creating a more complete trauma registry. The identification of malpositioned support lines and tubes allows for educational feedback to the first responders and trainees. Institutions with a low formal autopsy rate for trauma victims may benefit from developing a PMCT program.

Serious Complications of Intraosseous Access during Infant Resuscitation

We report on a 2.5-month-old infant with ischemia of the left leg and compartment following intraosseous needle application during resuscitation. Unfortunately, this event led to major limb amputation. The cause, mechanism, and prevention of this severe complication are discussed in this article.

Intraosseous Versus Intravenous Access in Pediatric Septic Shock Patients Admitted to Alexandria University Pediatric Intensive Care Unit

The cornerstone of emergency management of sepsis is early, goal-directed therapy. The purpose of this study was to evaluate the effect of intraosseous (IO) vs. intravenous (IV) access for resuscitation of patients with septic shock admitted to pediatric intensive care unit. This prospective interventional randomized clinical trial study was conducted on 60 patients with septic shock who need rapid administration of fluids and drugs; 30 cases were randomly chosen for IO vascular access, while the other 30 were selected for IV access. The IO route was successfully secured in all cases with a significant shorter time of vascular access insertion, shorter length of stay and reduction in mortality in IO group vs. IV group (p = 0.001, 0.045, 0.002, respectively). In pediatric emergencies, as in case of shock, the use of IO route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome.

Intramedullary placement of ventricular shunts: a review of using bone as a distal cerebrospinal absorption site in treating hydrocephalus

PURPOSE

Intraosseous (IO) vascular access has been used since the Second World War and is warranted when there is an emergency and/or urgent need to replenish the vascular pool. Despite long-term and satisfactory results from delivering large quantities of intravenous fluid via the medullary space of bone, use of this space for a distant receptacle for cerebrospinal fluid (CSF) diversion has seldom been considered.

METHODS

The current paper reviews the literature regarding the bony medullary space as a receptacle for intravenous fluid and CSF.

RESULTS

Previous authors have demonstrated the potential of the diploic space of the calvaria for CSF shunting. Pugh and colleagues tested the ability of the cranium to receive and absorb a small amount of tracer fluid.

CONCLUSION

The literature suggests that intraosseous placement of ventricular diversionary shunts is an alternative to more traditional sites such as the pleural cavity and peritoneum. When these latter locations are not available or are contraindicated, placement in the medullary space of bone is another option available to the surgeon.

Applied anatomy for tibial intraosseous access in adults: A Radioanatomical Study

Intraosseous access is a method for providing vascular access in resuscitation of critically ill and injured patients when traditional intravenous access is difficult or impossible. There is a lack of detailed description for the landmark for the insertion point in the literature. The aim of this study was to determine the exact location for intraosseous access. Radiographic computed tomography (CT) images of a total of 50 dry tibia bones were obtained. With 5-mm intervals, for all transverse images and by selecting transverse section, measurements were taken from the thickness of the cortex at anterior margin and mid-line medial surface, distance from anterior margin, and mid-line medial surface of the tibia to the posterior wall of medullar cavity, distance from anterior margin and mid-line medial surface of the tibia to the posterior surface of the tibia. The thinner part of the cortex of the tibia and the larger width of the medullar cavity is at 0.5 cm below the tibial tuberosity in the midline of the medial surface. The application region for proximal tibia access and landmark and most suitable insertion point for intraosseous infusion should be at level 0.5 cm below the tibial tuberosity in the midline of the medial surface. It was recommended that standard length for intraosseous canule should be 17 mm except for the thickness of skin. In conclusion, presented study provides certain localization for intraosseous access and standard length for intraosseous canule and this will be more effective in using this technique. Clin. Anat. 31:593-597, 2018. © 2017 Wiley Periodicals, Inc.

Establishing a Dedicated Difficult Vascular Access Team in the Emergency Department: A Needs Assessment

Peripheral vascular access is one of the most common procedures performed in emergency departments across the United States. Successful venipuncture is critical in providing timely diagnosis and treatments for patients. The aim of this article is to describe a needs assessment performed in a level-one academic emergency department to establish the need for a dedicated team for patients with difficult vascular access. Results from this assessment suggest that difficult vascular access represents tangible threats to patient safety and increased use of resources.

Comparison of time to obtain intraosseous versus jugular venous catheterization on canine cadavers

OBJECTIVE

To compare the time required and the success rate of personnel with 4 different levels of experience to place a humeral intraosseous (IO) catheter versus a jugular venous catheter (IV) in cadaver dogs.

DESIGN

Prospective study.

SETTING

Veterinary university teaching hospital.

INTERVENTIONS

Canine cadavers from recently euthanized dogs were obtained from the cadaver donation program between May and December 2014. Catheter placers (CPs) with varying clinical experience, including a first year emergency and critical care resident, a senior emergency veterinary technician (VTS certified), a final year veterinary student, and an ACVECC diplomate, participated in the study. Each CP catheterized a total of 6 dogs so that there was a total of 6 IO and 6 IV catheters placed, by automatic rotary insertion device (with an EZ-IO gun) and vascular cut-down technique, respectively, for each CP. Time for IO catheterization and IV catheterization was recorded and compared. The success of IO catheterization and IV catheterization was verified by visualization of an injection of iodinated contrast material under fluoroscopy within the medullary cavity or vessel.

ANIMALS

Twenty-four canine cadavers.

MEASUREMENTS AND MAIN RESULTS

Outcomes were analyzed using the Wilcoxon rank-sum test and the Kruskal-Wallis one-way analysis of variance. The median time for all IO catheterization operators was faster at 55.4 seconds (range 15.0-153.0 s) compared to the median time for all IV catherization operators at 217.3 seconds (range 55.6-614 s). The success rate for IO and IV was equal at 87.5%.

CONCLUSION

IO catheterization using an automatic rotary insertion device was performed more rapidly and successfully than jugular venous catheterization using a cut-down technique in canine cadaver. These findings suggest IO catheterization may be more efficient for gaining vascular access in the appropriate emergency clinical situations when preexisting IV access does not exist.

Effects of a new device to guide venous puncture in elderly critically ill patients: results of a pilot randomized study

BACKGROUND

Novel devices based on the emission of near-infrared electromagnetic radiation (NIR) have been developed to minimize venous puncture failures. These instruments produce an "augmented reality" image, in which subcutaneous veins are depicted on a LCD display. We compared the new technique with standard venipuncture in a population of elderly patients.

METHODS

Patients admitted in Intensive Care Unit were randomized to standard or to NIR assisted procedure.

RESULTS

In the 103 enrolled patients (age 74 ± 12 years; standard venipuncture-N = 56; NIR-N = 47), no differences were found in procedure length, number of attempts, and referred pain. With NIR there was a lower incidence of hematomas and fewer anxiety and depressive symptoms.

CONCLUSIONS

The use of the novel NIR-based device is safer and more psychologically tolerable, and it is not associated to an increase of procedure length or number of attempts.

Intraosseous access can be taught to medical students using the four-step approach

BACKGROUND

The intraosseous (IO) access is an alternative route for vascular access when peripheral intravascular catheterization cannot be obtained. In Denmark the IO access is reported as infrequently trained and used. The aim of this pilot study was to investigate if medical students can obtain competencies in IO access when taught by a modified Walker and Peyton's four-step approach.

METHODS

Nineteen students attended a human cadaver course in emergency procedures. A lecture was followed by a workshop. Fifteen students were presented with a case where IO access was indicated and their performance was evaluated by an objective structured clinical examination (OSCE) and rated using a weighted checklist. To evaluate the validity of the checklist, three raters rated performance and Cohen's kappa was performed to assess inter-rater reliability (IRR). To examine the strength of the overall IRR, Randolph's free-marginal multi rater kappa was used.

RESULTS

A maximum score of 15 points was obtained by nine (60%) of the participants and two participants (13%) scored 13 points with all three raters. Only one participant failed more than one item on the checklist. The expert rater rated lower with a mean score of 14.2 versus the non-expert raters with mean 14.6 and 14.3. The overall IRR calculated with Randolph's free-marginal multi rater kappa was 0.71.

CONCLUSION

The essentials of the IO access procedure can be taught to medical students using a modified version of the Walker and Peyton's four-step approach and the checklist used was found reliable.

Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand

BACKGROUND

Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients.

METHODS

We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model.

RESULTS

Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326).

CONCLUSION

Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines.

Ultrasound-Guided Peripheral Intravenous Catheter Training Results in Physician-Level Success for Emergency Department Technicians

OBJECTIVES

To report our success and complication rates with emergency department (ED) technician-performed ultrasound (US)-guided peripheral intravenous (IV) catheter placement and to compare our results to similar studies in the literature.

METHODS

We conducted a retrospective review of a prospective database of patients who underwent US-guided peripheral IV catheter placement attempts for clinical care in the ED. All patients meeting difficult IV access criteria who had a US-guided peripheral IV catheter placement attempted by a trained ED technician were included. Average attempts per success and overall success rates were compared to similar published studies.

RESULTS

There were 830 participants, with an overall success rate of ED technician- performed US-guided peripheral IV catheter placement of 97.5%. Clinicians categorized 82.6% of participants as having difficult IV access and reported that in 46.5%, a central venous catheter would have been necessary if the US-guided peripheral IV catheter failed. Of successful catheter attempts, 86.8% were placed on the first attempt; 11.6% were placed on the second attempt; and 1.6% were placed on the third attempt. For this study, the average number of attempts per success was 1.15 (95% confidence interval, 1.12-1.18), which was lower than in 6 other published studies, ranging from 1.27 to 1.70. The overall success rate of our ED technician-performed attempts was 0.970 (95% confidence interval, 0.956-0.983), which was higher than that reported in previous ED technician studies (0.79-0.80), and closer to that reported for physicians or nurses (0.87-0.97). The arterial puncture complication rate was 0.8%, which was also lower than in other published studies (1.25%-9.80%).

CONCLUSIONS

With brief but comprehensive training, ED technicians can successfully obtain US-guided peripheral IV catheter access in patients with difficult IV access.

Intraosseous access in trauma by air medical retrieval teams

Trauma accounts for a significant portion of overall mortality globally. Hemorrhage is the second major cause of mortality in the prehospital environment. Air medical retrieval services throughout the world have been developed to help improve the outcomes of patients suffering from a broad range of medical conditions, including trauma. These services often utilize intraosseous (IO) devices as an alternative means for access of both medically ill and traumatically injured patients in austere environments. However, studies have suggested that IO access cannot reach acceptable rates for massive transfusion. We review the subject to find the answer of whether IO access should be performed by air medical teams in the prehospital setting, or would central venous (CVC) access be more appropriate? We decided to assess the literature for capacity of IO access to meet resuscitation requirements in the prehospital management of trauma. We also decided to compare the insertion and complication characteristics of IO and CVC access.