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Singh A, Heeney M, Montgomery ME. The Pharmacologic Management of Cardiac Arrest. Cardiol Clin 2024; 42:279-288. [PMID: 38631795 DOI: 10.1016/j.ccl.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.
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Affiliation(s)
- Amandeep Singh
- Alameda Health System, Highland Hospital Emergency Department, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Megan Heeney
- Alameda Health System, Highland Hospital Emergency Department, 1411 East 31st Street, Oakland, CA 94602, USA
| | - Martha E Montgomery
- Alameda Health System, Highland Hospital Emergency Department, 1411 East 31st Street, Oakland, CA 94602, USA
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2
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Smida T, Crowe R, Jarvis J, Ratcliff T, Goebel M. Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation. PREHOSP EMERG CARE 2024; 28:779-786. [PMID: 38416867 DOI: 10.1080/10903127.2024.2321285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation. METHODS The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access. RESULTS After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access. CONCLUSION In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.
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Affiliation(s)
- Tanner Smida
- West Virginia University MD/PhD Program, Morgantown, West Virginia
| | | | - Jeffrey Jarvis
- Metropolitan Area EMS Authority, Fort Worth, Texas
- Department of Emergency Medicine, Texas A&M College of Medicine, Bryan, Texas
| | - Taylor Ratcliff
- Department of Emergency Medicine, Texas A&M College of Medicine, Bryan, Texas
| | - Mat Goebel
- University of Massachusetts Chan Medical School - Baystate, Springfield, Massachusetts
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Couper K, Ji C, Lall R, Deakin CD, Fothergill R, Long J, Mason J, Michelet F, Nolan JP, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Walker A, Chowdhury L, Norman C, Sprauve L, Starr K, Wood S, Bell S, Bradley G, Brown M, Brown S, Charlton K, Coppola A, Evans C, Evans C, Foster T, Jackson M, Kearney J, Lang N, Mellett-Smith A, Osborne R, Pocock H, Rees N, Spaight R, Tibbetts B, Whitley GA, Wiles J, Williams J, Wright A, Perkins GD. Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3). Resusc Plus 2024; 17:100544. [PMID: 38260121 PMCID: PMC10801302 DOI: 10.1016/j.resplu.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
Aims The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest. Methods PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained. Conclusion The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.
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Affiliation(s)
- Keith Couper
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chen Ji
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Rachael Fothergill
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - John Long
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Felix Michelet
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Henry Nwankwo
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael A Smyth
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Alison Walker
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
- Emergency Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | | | - Chloe Norman
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Kath Starr
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Sara Wood
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Steve Bell
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gemma Bradley
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Martina Brown
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Shona Brown
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison Coppola
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | | | - Christine Evans
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Michelle Jackson
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Justin Kearney
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | | | - Adam Mellett-Smith
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - Ria Osborne
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Helen Pocock
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Cwmbran, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | | | | | - Jason Wiles
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Julia Williams
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
- Department of Paramedic Science, University of Hertfordshire, Hatfield, UK
| | - Adam Wright
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gavin D Perkins
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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4
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Benner C, Jui J, Neth MR, Sahni R, Thompson K, Smith J, Newgard C, Daya MR, Lupton JR. Outcomes with Tibial and Humeral Intraosseous Access Compared to Peripheral Intravenous Access in Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:761-770. [PMID: 38015053 DOI: 10.1080/10903127.2023.2286621] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The optimal initial vascular access strategy for out-of-hospital cardiac arrest (OHCA) remains unknown. Our objective was to evaluate the association between peripheral intravenous (PIV), tibial intraosseous (TIO), or humeral intraosseous (HIO) as first vascular attempt strategies and outcomes for patients suffering OHCA. METHOD This was a secondary analysis of the Portland Cardiac Arrest Epidemiologic Registry, which included adult patients (≥18 years-old) with EMS-treated, non-traumatic OHCA from 2018-2021. The primary independent variable in our analysis was the initial vascular access strategy, defined as PIV, TIO, or HIO based on the first access attempt. The primary outcome for this study was the return of spontaneous circulation (ROSC) at emergency department (ED) arrival (a palpable pulse on arrival to the hospital). Secondary outcomes included survival to: admission, discharge, and discharge with a favorable outcome (Cerebral Perfusion Category score of ≤2). We conducted multivariable logistic regressions, adjusting for confounding variables and for clustering using a mixed-effects approach, with prespecified subgroup analyses by initial rhythm. RESULTS We included 2,993 patients with initial vascular access strategies of PIV (822 [27.5%]), TIO (1,171 [39.1%]), and HIO (1,000 [33.4%]). Multivariable analysis showed lower odds of ROSC at ED arrival (adjusted odds ratio [95% CI]) with TIO (0.79 [0.64-0.98]) or HIO (0.75 [0.60-0.93]) compared to a PIV-first strategy. These associations remained in stratified analyses for those with shockable initial rhythms (0.60 [0.41-0.88] and 0.53 [0.36-0.79]) but not in patients with asystole or pulseless electrical activity for TIO and HIO compared to PIV, respectively. There were no statistically significant differences in adjusted odds for survival to admission, discharge, or discharge with a favorable outcome for TIO or HIO compared to the PIV-first group in the overall analysis. Patients with shockable initial rhythms had lower adjusted odds of survival to discharge (0.63 [0.41-0.96] and 0.64 [0.41-0.99]) and to discharge with a favorable outcome (0.60 [0.39-0.93] and 0.64 [0.40-1.00]) for TIO and HIO compared to PIV, respectively. CONCLUSIONS TIO or HIO as first access strategies in OHCA were associated with lower odds of ROSC at ED arrival compared to PIV.
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Affiliation(s)
- Cameron Benner
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kathryn Thompson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey Smith
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Joshua R Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
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Brebner C, Asamoah-Boaheng M, Zaidel B, Yap J, Scheuermeyer F, Mok V, Christian M, Kawano T, Singh L, van Diepen S, Christenson J, Grunau B. The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests. Resuscitation 2023; 193:110031. [PMID: 37923113 DOI: 10.1016/j.resuscitation.2023.110031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
AIM Humeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes. METHODS We used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1-2) and survival at hospital discharge. RESULTS We included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4-9.4) and 6.1 minutes (IQR 4.1-8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90-2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83-2.01). Results using the full cohort were similar. CONCLUSIONS We did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.
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Affiliation(s)
- Callahan Brebner
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Asamoah-Boaheng
- Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Bianca Zaidel
- Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Justin Yap
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Frank Scheuermeyer
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Valerie Mok
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Christian
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Division of Critical Care Medicine, University of British Columbia, British Columbia, Canada; British Columbia Emergency Health Services, British Columbia, Canada
| | - Takahisa Kawano
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Lovepreet Singh
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Sean van Diepen
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jim Christenson
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Brian Grunau
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada; British Columbia Emergency Health Services, British Columbia, Canada.
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Kyle AI, Auten JD, Zarow GJ, Natarajan R, Bianchi WD, Speicher MV, Palma J, Gaspary MJ. Determining Intraosseous Needle Placement Using Point-of-Care Ultrasound in a Swine (Sus scrofa) Model. Mil Med 2023; 188:2969-2974. [PMID: 35476019 DOI: 10.1093/milmed/usac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/17/2022] [Accepted: 04/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Intraosseous (IO) access is critical in resuscitation, providing rapid access when peripheral vascular attempts fail. Unfortunately, misplacement commonly occurs, leading to possible fluid extravasation and tissue necrosis. Current research exploring the utility of bedside ultrasound in confirming IO line placement is limited by small sample sizes of skeletally immature subjects or geriatric cadaveric models. The objective of this study was to investigate the potential value of ultrasound confirming IO needle placement in a live tissue model with bone densities approximated to the young adult medical or trauma patient. MATERIALS AND METHODS In this randomized, blinded prospective study, IO devices were placed into the bilateral humeri of 36 sedated adult swine (N = 72) with bone densities approximating that of a 20-39-year-old adult. Of the 72 lines, 53 were randomized to the IO space ("correct") and 19 into the subcutaneous tissue ("incorrect"). Four emergency physicians with variable ultrasound experience and blinded to needle location independently assessed correct or incorrect needle placements based on the presence of an intramedullary "flare" on color power Doppler (CPD) during a saline flush. Participants adjusted the ultrasound beam trajectory and recorded assessments up to three times, totaling 204 separate observations. RESULTS Overall, sensitivity for placement confirmation was 72% (95% CI: 64%-79%). Specificity was 79% (95% CI: 66%-89%). First assessment and final assessment results were similar. More experienced sonographers demonstrated greater success in identifying inaccurate placements with a specificity of 86% (95% CI: 63%-96%). CONCLUSION Within the context of this study, point-of-care ultrasound with CPD did not reliably confirm IO line placement. However, more accurate assessments of functional and malpositioned catheters were noted in sonographers with greater than 4 years of experience. Future study into experienced sonographers' use of CPD to confirm IO catheter placement is needed.
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Affiliation(s)
- Adrianna I Kyle
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Jonathan D Auten
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | | | - Ramesh Natarajan
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - William D Bianchi
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Matthew V Speicher
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - James Palma
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Micah J Gaspary
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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Singh A, Heeney M, Montgomery ME. The Pharmacologic Management of Cardiac Arrest. Emerg Med Clin North Am 2023; 41:559-572. [PMID: 37391250 DOI: 10.1016/j.emc.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.
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Affiliation(s)
- Amandeep Singh
- Alameda Health System, Highland Hospital Emergency Department, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Megan Heeney
- Alameda Health System, Highland Hospital Emergency Department, 1411 East 31st Street, Oakland, CA 94602, USA
| | - Martha E Montgomery
- Alameda Health System, Highland Hospital Emergency Department, 1411 East 31st Street, Oakland, CA 94602, USA
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8
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Wang D, Deng L, Zhang R, Zhou Y, Zeng J, Jiang H. Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:17. [PMID: 36918947 PMCID: PMC10012735 DOI: 10.1186/s13017-023-00487-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
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.
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Affiliation(s)
- Dong Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Lei Deng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruipeng Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Yiyue Zhou
- Department of Biology, Sorbonne University, 75005, Paris, France
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China. .,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China. .,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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9
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Matte AE, Vossenberg NE, Akers KG, Paxton JH. Intraosseous Vascular Access in Cardiac Arrest: A Systematic Review of the Literature, with Implications for Future Research. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2023. [DOI: 10.1007/s40138-023-00259-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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10
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Palazzolo A, Akers KG, Paxton JH. Complications of Intraosseous Catheterization in Adult Patients: A Review of the Literature. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2023. [DOI: 10.1007/s40138-023-00261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Muacevic A, Adler JR, Lubin JS. The Ability of Paramedics to Accurately Locate Correct Anatomical Sites for Intraosseous Needle Insertion. Cureus 2023; 15:e33355. [PMID: 36751187 PMCID: PMC9897230 DOI: 10.7759/cureus.33355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/05/2023] Open
Abstract
Introduction Intraosseous (IO) access is an alternative to peripheral intravenous access, in which a needle is inserted through the cortical bone into the medullary space using either a manual driver or an electric drill. Although studies report high success rates of IO access, failures are often attributed to incorrect site placement due to failure to adhere to anatomical landmarks. This study was designed to evaluate the ability of paramedics to locate the correct anatomic location for IO needle insertion. Methods Participants were paramedics who were recruited at Pennsylvania's annual statewide Emergency Medical Services (EMS) conference. After completing a demographics survey which included information about their training and practice environment, they were asked to identify which IO sites were permitted for IO placement using the EZ IO® drill and to place a sticker at those locations on a human volunteer. A transfer sheet was utilized, and the distance between the participants' sticker and the location as marked by a physician board-certified in both Emergency Medicine and Emergency Medical Services was recorded. Descriptive statistics and t-tests were calculated from the records. Results Of 30 paramedics who participated in the study, 25 (83%) had been in practice for more than five years (range: 1-37 years), 13 (46%) reported running more than 20 calls per week, and 23 (79%) reported that they only or mostly provide 9-1-1 EMS response. Ten (36%) participants were currently certified in PHTLS, and 16 (57%) had previously been PHTLS certified. All participants reported having been trained in IO insertion. Seventeen (57%) reported having utilized an IO ≤10 times in the field, and 13 (43%) reported >10 field IO insertions. When asked to identify appropriate IO insertion sites for the EZ IO drill, 26 paramedics (90%) correctly identified both the proximal humerus and proximal tibia. The average distance from the landmark for the humeral insertion site was 5.06 cm, with a statistically significant difference in the means for those who did and did not rotate the arm internally before identifying the humeral IO insertion site (p < .01). The average distance from the landmark at the tibial insertion site was 4.13 cm. Conclusion Although a high percentage of paramedics were able to verbally identify the correct location for IO placement, fewer were able to locate the insertion site on a human volunteer. Our results suggest a need for hands-on refresher training to maintain competency at IO insertion, as it is a rarely utilized procedure in the field.
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Eifinger F, Scaal M, Wehrle L, Maushake S, Fuchs Z, Koerber F. Finding alternative sites for intraosseous infusions in newborns. Resuscitation 2021; 163:57-63. [PMID: 33862177 DOI: 10.1016/j.resuscitation.2021.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/17/2021] [Accepted: 04/01/2021] [Indexed: 02/04/2023]
Abstract
AIM Intraosseous (IO)-access plays an alternative route during resuscitation. Our study in preterm and term stillborns was performed to find alternative IO puncture sites beside the recommended proximal tibia. METHODS The cadavers used were legal donations. 20 stillborns (mean: 29.2weeks, IQR 27.1-39.6) were investigated. Spectral-CT were analysed to calculate the diameter and circumferences of: i) proximal humerus ii) distal femur iii) proximal tibia iv) diaphyseal tibial. Contrast medium was applied under video documentation to investigate the drainage into the vascular system. RESULTS In term newborns, diameter of the cortex of the proximal humeral head is 12.1 ± 1.8 mm, distal end of the femur 11.9 ± 3.4 mm and the proximal tibial bone 12.0 ± 2.4 mm with cross-sectional diameter of 113.5 ± 19.7 mm2, 120.6 ± 28.2 mm2 and 111.6 ± 29.5 mm2, respectively. Regarding the preterm groups, there is a strong age-related growth in diameter and cross -sectional size. The diaphyseal area is the smallest in all measured bones with an age-dependent increase and is about half of that of metaphyseal diameters (proximal and distal) and about one third of that of metaphyseal cross sectional areas. The proximal femoral head region has the largest diameter of all measured bones with an egg-shaped formation with an extensive joint capsula. All investigated metaphyseal areas lack a clearly enclosed bone marrow cavity. Infusion of contrast medium into the distal femoral end and the proximal humerus head demonstrate the drainage of contrast medium into the central venous system within seconds. CONCLUSION Proximal humeral head and distal femoral end might be alternative IO areas which may lead to further IO puncture sites in neonates.
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Affiliation(s)
- Frank Eifinger
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany.
| | - Martin Scaal
- Institute of Anatomy II, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Lukas Wehrle
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Stien Maushake
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Zeynep Fuchs
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Friederike Koerber
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
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Bustamante S, Bajracharya GR, Cheruku S, Leung S, Mao G, Singh A, Mamoun N. Point-of-Care Ultrasound to Identify Landmarks of the Proximal Humerus: Potential Use for Intraosseous Vascular Access. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:725-730. [PMID: 32881005 DOI: 10.1002/jum.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/05/2020] [Accepted: 07/06/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Sergio Bustamante
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gausan Ratna Bajracharya
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shravan Cheruku
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steve Leung
- Department of Radiology, Metro Health, Cleveland, Ohio, USA
| | - Guangmai Mao
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences Cleveland Clinic, Cleveland, Ohio, USA
| | - Asha Singh
- Department of Anesthesiology and Perioperative Medicine, University Hospitals, Cleveland Medical Center, Cleveland, Ohio, USA
| | - Negmeldeen Mamoun
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Philbeck TE, Puga TA, Montez DF, Davlantes C, DeNoia EP, Miller LJ. 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. J Vasc Access 2021; 23:339-347. [PMID: 33541218 DOI: 10.1177/1129729821992667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas E Philbeck
- Department of Clinical and Medical Affairs, Teleflex Medical Incorporated, San Antonio, TX, USA
| | - Tatiana A Puga
- Department of Clinical and Medical Affairs, Teleflex Medical Incorporated, San Antonio, TX, USA
| | - Diana F Montez
- Department of Clinical and Medical Affairs, Teleflex Medical Incorporated, San Antonio, TX, USA
| | - Chris Davlantes
- Department of Clinical and Medical Affairs, Teleflex Medical Incorporated, San Antonio, TX, USA
| | - Emanuel P DeNoia
- Department of Clinical Operations, ICON Early Phase Services, San Antonio, TX, USA
| | - Larry J Miller
- Department of Clinical Operations, ICON Early Phase Services, San Antonio, TX, USA
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15
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Tan BKK, Chin YX, Koh ZX, Md Said NAZB, Rahmat M, Fook-Chong S, Ng YY, Ong MEH. Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest. Resuscitation 2020; 159:129-136. [PMID: 33221362 DOI: 10.1016/j.resuscitation.2020.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/27/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to determine if using intraosseous (IO) access when intravenous (IV) access fails improves outcomes. METHODS This was a prospective, parallel-group, cluster-randomised study that compared 'IV only' against 'IV + IO' in OHCA patients, where if 2 IV attempts failed or took more than 90 s, paramedics had 2 further attempts of IO. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were insertion success rate, adrenaline administration, time to adrenaline and survival outcome. RESULTS A total of 1007 patients were included in the analysis. An Intention To Treat analysis showed a significant difference in success rates of obtaining vascular access in the IV + IO arm compared to the IV arm (76.6% vs 61.1% p = 0.001). There were significantly more patients in the IV + IO arm than the IV arm being administered prehospital adrenaline (71.3% vs 55.4% p = 0.001). The IV + IO arm also received adrenaline faster compared to the IV arm in terms of median time from emergency call to adrenaline (23 min vs 25 min p = 0.001). There was no significant difference in ROSC (adjusted OR 0.99 95%CI: 0.75-1.29), survival to discharge or survival with CPC 2 or better in both groups. A Per Protocol analysis also showed there was higher success in obtaining vascular access in the IV + IO arm, but ROSC and survival outcomes were not statistically different. CONCLUSION Using IO when IV failed led to a higher rate of vascular access, prehospital adrenaline administration and faster adrenaline administration. However, it was not associated with higher ROSC, survival to discharge, or good neurological outcome.
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Affiliation(s)
- Boon Kiat Kenneth Tan
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Yun Xin Chin
- Department of Anaesthesiology, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore
| | | | - Masnita Rahmat
- Medical Department, Singapore Civil Defence Force, 91 Ubi Avenue 4, 408827, Singapore
| | - Stephanie Fook-Chong
- Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Yih Yng Ng
- Home Team Medical Services Division, Ministry of Home Affairs, 28 Irrawaddy Road, 329560, Singapore; Emergency Department, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore; Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
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Wang J, Fang Y, Ramesh S, Zakaria A, Putman MT, Dinescu D, Paik J, Geocadin RG, Tahsili-Fahadan P, Altaweel LR. Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension. Neurocrit Care 2020; 30:364-371. [PMID: 30397844 DOI: 10.1007/s12028-018-0637-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jing Wang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Yun Fang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Subhashini Ramesh
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Asma Zakaria
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Maryann T Putman
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Dan Dinescu
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - James Paik
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Romergryko G Geocadin
- Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Pouya Tahsili-Fahadan
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA.,Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Laith R Altaweel
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA. .,Neuroscience Research, Neuroscience and Spine Institute, INOVA Fairfax Hospital, Falls Church, VA, USA.
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Gendron B, Cronin A, Monti J, Brigg A. Military Medic Performance with Employment of a Commercial Intraosseous Infusion Device: A Randomized, Crossover Study. Mil Med 2019; 183:e216-e222. [PMID: 29420766 DOI: 10.1093/milmed/usx078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/03/2017] [Indexed: 11/12/2022] Open
Abstract
Background Obtaining intraosseous (IO) access remains an invaluable skill in the management and resuscitation of patients on the battlefield. The U.S. Army Combat Medic is currently trained to utilize a sternal IO device (FAST1® Intraosseous Infusion System); however, the Arrow® EZ-IO® Intraosseous Vascular Access System offers unique benefits including ease of use, reload ability, and placement location versatility. Studies have demonstrated high success rates in the operational settings using the EZ-IO® System; however, no prospective studies have been conducted to assess the performance of U.S. Army's conventional Combat Medics using the EZ-IO® System. We hypothesized that EZ-IO® System-naïve medics would have a statistically significant success rate advantage utilizing the proximal tibia approach versus proximal humerus approach. Methods A total of 77 U.S. Army Medics (Military Occupational Specialty [MOS] 68 W) volunteer participants were recruited to participate in this randomized, crossover study. Participants received a standardized audio-visual-enhanced lecture on EZ-IO® System use without hands-on training and then randomized into two study groups according to which anatomical approach they would attempt first. Results were analyzed to determine participants' first-attempt mean success rates, mean required time to properly place the needle into simulated humeral head and proximal tibial bone models, and mean survey results measuring the participant's subjective assessment of the two approaches to include, along with training and testing experience. The data of those not naïve to the employment of the EZ-IO® System were excluded. Results The primary outcome measurement of overall mean participant success rate with attempted insertions into proximal tibial and humeral head bone models was 88% and 86%, respectively, demonstrating no statistically significant difference by approach, with no significant learning or design confounding effects (p > 0.05). Secondary outcomes of mean procedural time and subjective comfort and skill benefit were reported. Successful procedure times between the two anatomical approaches demonstrated a statistically significant mean time advantage of 17.1 s (p < 0.05) in proximal tibia IO placement. Overall participant mean subjective comfort level utilizing the EZ-IO® System (0- to 10-point scale with a 0 being not comfortable and a 10 being very comfortable) was 8.2, with no statistically significant difference in comfort discovered when comparing the two approaches. Participants reported a mean subjective score (0-10 scale with a 0 providing no benefit and a 10 providing extreme benefit) of 9.3 when asked how beneficial their newly learned IO system skill was to their overall medical skillset. Conclusions The overall first-attempt success rates of U.S. Army Combat Medics employing the EZ-IO® System are similar to the success rates of FAST1® device employment and similar to the success of other provider cohorts using the EZ-IO® device. Coupled with perceived benefit of adding the EZ-IO® System to their combat medic skillset, these data warrant further study and consideration for the incorporation of commercial IO systems into U.S. Army Combat Medic initial, sustainment, and pre-combat training and standard issue equipment.
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Affiliation(s)
- Brett Gendron
- U.S. Army Baylor EMPA Residency Program, Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
| | - Aaron Cronin
- U.S. Army Baylor EMPA Residency Program, Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
| | - Jonathan Monti
- U.S. Army Baylor EMPA Residency Program, Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
| | - Andrew Brigg
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
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Eriksson M, Larsson A, Lipcsey M, Strandberg G. The effect of hemorrhagic shock and intraosseous adrenaline injection on the delivery of a subsequently administered drug - an experimental study. Scand J Trauma Resusc Emerg Med 2019; 27:29. [PMID: 30850019 PMCID: PMC6408834 DOI: 10.1186/s13049-018-0569-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/11/2018] [Indexed: 11/29/2022] Open
Abstract
Background Intraosseous (IO) access is a recommended method when venous access cannot be rapidly established in an emergency. Experimental data suggest that major hemorrhage and catecholamine administration both reduce bone marrow blood flow. We studied the uptake of gentamicin as a tracer substance administered IO following adrenaline administration in hemorrhagic shock and in cardiac arrest. Methods Twenty anesthetized pigs underwent hemorrhage corresponding to 50% of the blood volume. They then received injections of either; adrenaline IO (n = 5), saline IO n = 5), adrenaline IO during cardiac arrest and cardiopulmonary resuscitation (CPR, n = 5), or intravenous adrenaline. The injections were followed by an injection of gentamicin by the same route. Doses and volumes were equivalent among the groups. In all animals, mixed venous antibiotic concentrations were analyzed at 5, 15 and 30 min after administration. Results Mean (SD) plasma gentamicin concentrations (mg x L− 1) at 5 min were 26.4 (2.3) in the group with previous IO adrenaline administration, 26.6 (4.5) in the IO saline group, 31. 2 (12) in the IO adrenaline + CPR group and 23 (4.5) in the IV group. Concentrations in the CPR group were significantly higher than the others. Conclusions No impairment of drug uptake with IO administration after recent IO adrenaline exposure was demonstrable in this shock model.
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Affiliation(s)
- Mats Eriksson
- Section of Anesthesiology & Intensive Care, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
| | - Anders Larsson
- Section of Clinical Chemistry, Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Miklós Lipcsey
- Section of Anesthesiology & Intensive Care, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Gunnar Strandberg
- Section of Anesthesiology & Intensive Care, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. J Trauma Acute Care Surg 2019; 84:558-563. [PMID: 29300281 DOI: 10.1097/ta.0000000000001795] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Quick and successful vascular access in injured patients arriving in extremis is crucial to enable early resuscitation and rapid OR transport for definitive repair. We hypothesized that intraosseous (IO) access would be faster and have higher success rates than peripheral intravenous (PIV) or central venous catheters (CVCs). METHODS High-definition video recordings of resuscitations for all patients undergoing emergency department thoracotomy from April 2016 to July 2017 were reviewed as part of a quality improvement initiative. Demographics, mechanism of injury, access type, access location, start and stop time, and success of each vascular access attempt were recorded. Times to completion for access types (PIV, IO, CVC) were compared using Kruskal-Wallis test adjusted for multiple comparisons, while categorical outcomes, such as success rates by access type, were compared using χ test or Fisher's exact test. RESULTS Study patients had a median age of 30 years (interquartile range [IQR], 25-38 years), 92% were male, 92% were African American, and 93% sustained penetrating trauma. A total of 145 access attempts in 38 patients occurred (median, 3.8; SD, 1.4 attempts per patient). There was no difference between duration of PIV and IO attempts (0.63; IQR, 0.35-0.96 vs. 0.39 IQR, 0.13-0.65 minutes, adjusted p = 0.03), but both PIV and IO were faster than CVC attempts (3.2; IQR, 1.72-5.23 minutes; adjusted p < 0.001 for both comparisons). Intraosseous lines had higher success rates than PIVs or CVCs (95% vs. 42% vs. 46%, p < 0.001). CONCLUSION Access attempts using IO are as fast as PIV attempts but are more than twice as likely to be successful. Attempts at CVC access in patients in extremis have high rates of failure and take a median of over 3 minutes. While IO access may not completely supplant PIVs and CVCs, IO access should be considered as a first-line therapy for trauma patients in extremis. LEVEL OF EVIDENCE Therapeutic, level III.
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Insights From a Tertiary Care Intraosseous Insertion Practice Improvement Registry: A 2-Year Descriptive Analysis. J Emerg Nurs 2018; 45:155-160. [PMID: 30322676 DOI: 10.1016/j.jen.2018.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Few practice improvement registries exist that describe opportunities to improve intraosseous (IO) use. The goal of this project was to assess the success rate of the procedure by emergency nurses and identify opportunities to improvement. Secondary goals were to assess success rates based on clinician type, age of patient, and procedural factors. METHODS Emergency nurses assigned to the resuscitation area of a tertiary care emergency department completed an education module and skill lab on IO placement. Tracking forms were completed whenever IO access was attempted, and the clinical nurse educator collated the forms. RESULTS Over 2 years, quality improvement forms were submitted for 17 pediatric patients (receiving 23 IO insertions) and 35 adult patients (receiving 40 intraosseous insertions). Prior to an IO attempt, the average number of IV attempts for pediatric and adult patients was 4 (range 0 to 10) and 2 (0 to 5), respectively. Successful pediatric IO insertion rate was 6/15 (40%) for physicians (both residents and attending physicians) and 6/7 (86%) for emergency nurses. Physicians were more likely to perform IO insertions in children <12 months of age and emergency nurses in patients >12 months of age. The leading cause of failed insertions in pediatrics was selecting a needle that was too short: either not reaching the intramedullary canal or quickly becoming dislodged, especially with flushing the IO cannula after insertion. For adult patients, IO insertion success rates for physicians were 13/14 (93%) and 18/20 (90%) for emergency nurses. DISCUSSION The registry identified opportunities to improve clinical practice on the clinical threshold for IO use in pediatric patients and the appropriate selection of IO cannula.
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21
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Slocum AH, Reinitz SD, Jariwala SH, Van Citters DW. Design, Development, and Validation of an Intra-Osseous Needle Placement Guide. J Med Device 2017. [DOI: 10.1115/1.4037442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander H. Slocum
- Mem. ASME Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin, 1155 N. Mayfair Road, Wauwatosa, WI 53226 e-mail:
| | - Steven D. Reinitz
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755
| | - Shailly H. Jariwala
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755 e-mail:
| | - Douglas W. Van Citters
- Mem. ASME Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755
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Abstract
OBJECTIVE Current guidelines recommend the use of intraosseous access when IV access is not readily attainable. The pediatric literature reports an excellent safety profile, whereas only small prospective studies exist in the adult literature. We report a case of vasopressor extravasation and threatened limb perfusion related to intraosseous access use and our management of the complication. We further report our subsequent systematic review of intraosseous access in the adult population. DATA SOURCES Ovid Medline was searched from 1946 to January 2015. STUDY SELECTION Articles pertaining to intraosseous access in the adult population (age greater than or equal to 14 years) were selected. Search terms were "infusion, intraosseous" (all subfields included), and intraosseous access" as key words. DATA EXTRACTION One author conducted the initial literature review. All authors assessed the methodological quality of the studies and consensus was used to ensure studies met inclusion criteria. DATA SYNTHESIS The case of vasopressor extravasation was successfully treated with pharmacologic interventions, which reversed the effects of the extravasated vasopressors: intraosseous phentolamine, topical nitroglycerin ointment, and intraarterial verapamil and nitroglycerin. Our systematic review of the adult literature found 2,332 instances of intraosseous insertion. A total of 2,106 intraosseous insertion attempts were made into either the tibia or the humerus; 192 were unsuccessful, with an overall success rate of 91%. Five insertions were associated with serious complications. A total of 226 insertion attempts were made into the sternum; 54 were unsuccessful, with an overall success rate of 76%. CONCLUSIONS Intraosseous catheter insertion provides a means for rapid delivery of medications to the vascular compartment with a favorable safety profile. Our systematic literature review of adult intraosseous access demonstrates an excellent safety profile with serious complications occurring in 0.3% of attempts. We report an event of vasopressor extravasation that was potentially limb threatening. Therapy included local treatment and injection of intraarterial vasodilators. Intraosseous access complications should continue to be reported, so that the medical community will be better equipped to treat them as they arise.
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Afzali M, Kvisselgaard AD, Lyngeraa TS, Viggers S. Intraosseous access can be taught to medical students using the four-step approach. BMC MEDICAL EDUCATION 2017; 17:50. [PMID: 28253870 PMCID: PMC5335802 DOI: 10.1186/s12909-017-0882-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 02/07/2017] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Monika Afzali
- Department of Anaesthesiology, University Hospital of Copenhagen, Herlev, Denmark
- Cochrane Anaesthesia, Critical and Emergency Care, The Cochrane Collaboration, Herlev, Denmark
| | - Ask Daffy Kvisselgaard
- Students’ Society of Anaesthesiology & Traumatology, Faculty of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | | | - Sandra Viggers
- Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark, Herlev, Denmark
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Blueprint for Implementing New Processes in Acute Care: Rescuing Adult Patients With Intraosseous Access. J Trauma Nurs 2017; 22:266-73. [PMID: 26352658 DOI: 10.1097/jtn.0000000000000152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The intraosseous (IO) access initiative at an urban university adult level 1 trauma center began from the need for a more expeditious vascular access route to rescue patients in extremis. The goal of this project was a multidisciplinary approach to problem solving to increase access of IO catheters to rescue patients in all care areas. The initiative became a collaborative effort between nursing, physicians, and pharmacy to embark on an acute care endeavor to standardize IO access. This is a descriptive analysis of processes to effectively develop collaborative strategies to navigate hospital systems and successfully implement multilayered initiatives. Administration should empower nurse to advance their practice to include IO for patient rescue. Intraosseous access may expedite resuscitative efforts in patients in extremis who lack venous access or where additional venous access is required for life-saving therapies. Limiting IO dwell time may facilitate timely definitive venous access. Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is optimal for maintaining proficiency and knowledge. More research opportunities exist to determine medication safety and efficacy in adult patients in the acute care setting.
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Kehrl T, Becker BA, Simmons DE, Broderick EK, Jones RA. Intraosseous access in the obese patient: assessing the need for extended needle length. Am J Emerg Med 2016; 34:1831-4. [DOI: 10.1016/j.ajem.2016.06.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/21/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022] Open
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CT angiography of the chest and abdomen in an emergency patient via humeral intraosseous access. Emerg Radiol 2016; 24:105-108. [PMID: 27572932 DOI: 10.1007/s10140-016-1438-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/24/2016] [Indexed: 10/21/2022]
Abstract
A 69-year-old woman was taken to our emergency department after having been found unconscious. An intraosseous catheter was placed in the head of the right humerus due to inaccessible peripheral veins. With the suspected diagnosis of shock, pulmonary embolism, and mesenteric ischemia, a CT scan of the chest and abdomen was initiated. Pulmonary embolism and mesenteric arterial embolism could be ruled out at excellent image quality.
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Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:102. [PMID: 27075364 PMCID: PMC4831096 DOI: 10.1186/s13054-016-1277-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 03/31/2016] [Indexed: 11/10/2022]
Abstract
Background Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of knowlegde and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures, the contraindications of the technique, and modalities for catheter implementation and skill acquisition. Methods A PubMed search for all articles published up to December 2015 was performed by using the terms “Intra-osseous” AND “Adult”. Additional articles were included by using the “related citations” feature of PubMed or checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the articles that the search yielded were independently screened for eligibility by two authors and included in the analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for answering the following question “when, how, and for which population should an IO infusion be used in adults” were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the drafts together, resolved disagreements by consensus with all the authors, and decided on the final version. Results IO infusion should be implemented in all critical situations when peripheral venous access is not easily obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains underused in adults even though learning the technique is rapid and easy. Conclusions Indications for IO infusion use in adults requiring urgent parenteral access and having difficult intravenous access are increasing. Physicians working in emergency departments or intensive care units should learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the possibilities this access offers. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1277-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Petitpas
- Department of Anesthesiology and Intensive Care, University Hospital of Poitiers, 86021 Poitiers, France.,Laboratory of Anatomy, Biomechanics and Simulation, University Hospital of Poitiers, 86021, Poitiers, France
| | - J Guenezan
- Emergency Department, University Hospital of Poitiers, 86021 Poitiers, France.
| | - T Vendeuvre
- Orthopedic Surgical Department, University Hospital of Poitiers, 86021, Poitiers, France
| | - M Scepi
- Laboratory of Anatomy, Biomechanics and Simulation, University Hospital of Poitiers, 86021, Poitiers, France.,Emergency Department, University Hospital of Poitiers, 86021 Poitiers, France
| | - D Oriot
- Laboratory of Anatomy, Biomechanics and Simulation, University Hospital of Poitiers, 86021, Poitiers, France.,Pediatric Emergency Department, University Hospital of Poitiers, 86021, Poitiers, France
| | - O Mimoz
- Department of Anesthesiology and Intensive Care, University Hospital of Poitiers, 86021 Poitiers, France.,Emergency Department, University Hospital of Poitiers, 86021 Poitiers, France
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Fulkerson J, Lowe R, Anderson T, Moore H, Craig W, Johnson D. Effects of Intraosseous Tibial vs. Intravenous Vasopressin in a Hypovolemic Cardiac Arrest Model. West J Emerg Med 2016; 17:222-8. [PMID: 26973756 PMCID: PMC4786250 DOI: 10.5811/westjem.2015.12.28825] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/10/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction This study compared the effects of vasopressin via tibial intraosseous (IO) and intravenous (IV) routes on maximum plasma concentration (Cmax), the time to maximum concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a hypovolemic cardiac arrest model. Methods This study was a randomized prospective, between-subjects experimental design. A computer program randomly assigned 28 Yorkshire swine to one of four groups: IV (n=7), IO tibia (n=7), cardiopulmonary resuscitation (CPR) + defibrillation (n=7), and a control group that received just CPR (n=7). Ventricular fibrillation was induced, and subjects remained in arrest for two minutes. CPR was initiated and 40 units of vasopressin were administered via IO or IV routes. Blood samples were collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes. CPR and defibrillation were initiated for 20 minutes or until ROSC was achieved. We measured vasopressin concentrations using high-performance liquid chromatography. Results There was no significant difference between the IO and IV groups relative to achieving ROSC (p=1.0) but a significant difference between the IV compared to the CPR+ defibrillation group (p=0.031) and IV compared to the CPR-only group (p=0.001). There was a significant difference between the IO group compared to the CPR+ defibrillation group (p=0.031) and IO compared to the CPR-only group (p=0.001). There was no significant difference between the CPR + defibrillation group and the CPR group (p=0.127). There was no significant difference in Cmax between the IO and IV groups (p=0.079). The mean ± standard deviation of Cmax of the IO group was 58,709±25, 463pg/mL compared to the IV group, which was 106,198±62, 135pg/mL. There was no significant difference in mean Tmax between the groups (p=0.084). There were no significant differences in odds of ROSC between the tibial IO and IV groups. Conclusion Prompt access to the vascular system using the IO route can circumvent the interruption in treatment observed with attempting conventional IV access. The IO route is an effective modality for the treatment of hypovolemic cardiac arrest and may be considered first line for rapid vascular access.
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Affiliation(s)
- Justin Fulkerson
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Robert Lowe
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Tristan Anderson
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Heather Moore
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - William Craig
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Don Johnson
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
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Joanne G, Stephen P, Susan S. Intraosseous vascular access in critically ill adults-a review of the literature. Nurs Crit Care 2015; 21:167-77. [PMID: 25688586 DOI: 10.1111/nicc.12163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 12/04/2014] [Accepted: 01/07/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Garside Joanne
- Division of acute care; University of Huddersfield; Queensgate, Huddersfield, West Yorkshire UK
| | - Prescott Stephen
- Division of acute care; University of Huddersfield; Queensgate, Huddersfield, West Yorkshire UK
| | - Shaw Susan
- Calderdale and Huddersfield NHS Foundation Trust; Halifax UK
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Helm M, Haunstein B, Schlechtriemen T, Ruppert M, Lampl L, Gäßler M. EZ-IO(®) intraosseous device implementation in German Helicopter Emergency Medical Service. Resuscitation 2014; 88:43-7. [PMID: 25553609 DOI: 10.1016/j.resuscitation.2014.12.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/10/2014] [Accepted: 12/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraosseous access (IO) is a rapid and safe alternative when peripheral venous access is difficult. Our aim was to summarize the first three years experience with the use of a semi-automatic IO device (EZ-IO(®)) in German Helicopter Emergency Medical Service (HEMS). METHODS Included were all patients during study period (January 2009-December 2011) requiring an IO access performed by HEMS team. Outcome variables were IO rate, IO insertion success rates, site of IO access, type of EZ-IO(®) needle set used, strategy of vascular access, procedure related problems and operator's satisfaction. RESULTS IO rate was 0.3% (348/120.923). Overall success rate was 99.6% with a first attempt success rate of 85.9%; there was only one failure (0.4%). There were three insertion sites: proximal tibia (87.2%), distal tibia (7.5%) and proximal humerus (5.3%). Within total study group IO was predominantly the second-line strategy (39% vs. 61%, p<0.001), but in children<7 years, in trauma cases and in cardiac arrest IO was more often first-line strategy (64% vs. 28%, p<0.001; 48% vs. 34%, p<0.032; 50% vs. 29%, p<0.002 respectively). Patients with IO access were significantly younger (41.7±28.7 vs. 56.5±24.4 years; p<0.001), more often male (63.2% vs. 57.7%; p=0.037), included more trauma cases (37.3% vs. 30.0%; p=0.003) and more often patients with a NACA-Score≥5 rating (77.0% vs. 18.6%; p<0.001). Patients who required IO access generally presented with more severely compromised vital signs associated with the need for more invasive resuscitation actions such as intubation, chest drains, CPR and defibrillation. In 93% EZ-IO(®) needle set handling was rated "good". Problems were reported in 1.6% (needle dislocation 0.8%, needle bending 0.4% and parafusion 0.4%). CONCLUSIONS The IO route was generally used in the most critically ill of patients. Our relatively low rate of usage would indicate that this would be compatible with the recommendations of established guidelines. The EZ-IO(®) intraosseous device proved feasible with a high success rate in adult and pediatric emergency patients in HEMS.
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Affiliation(s)
- Matthias Helm
- Department of Anaesthesiology & Intensive Care Medicine - Section Emergency Medicine/HEMS "Christoph 22", Armed Forces Medical Centre Ulm, Germany.
| | - Benedikt Haunstein
- Department of Anaesthesiology & Intensive Care Medicine - Section Emergency Medicine/HEMS "Christoph 22", Armed Forces Medical Centre Ulm, Germany
| | - Thomas Schlechtriemen
- Medical Quality Management - ADAC Luftrettung (Subsidiary of the German Automobile Association), Munich, Germany
| | - Matthias Ruppert
- Department of Medicine - ADAC Luftrettung (Subsidiary of the German Automobile Association), Munich, Germany
| | - Lorenz Lampl
- Department of Anaesthesiology & Intensive Care Medicine - Section Emergency Medicine/HEMS "Christoph 22", Armed Forces Medical Centre Ulm, Germany
| | - Michael Gäßler
- Department of Medicine - ADAC Luftrettung (Subsidiary of the German Automobile Association), Munich, Germany
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Abstract
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.
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Abstract
Abstract
Intraosseous vascular access is a time-tested procedure which has been incorporated into the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation. Intravenous access is often difficult to achieve in shock patients, and central line placement can be time consuming. Intraosseous vascular access, however, can be achieved quickly with minimal disruption of chest compressions. Newer insertion devices are easy to use, making the intraosseous route an attractive alternative for venous access during a resuscitation event. It is critical that anesthesiologists, who are often at the forefront of patient resuscitation, understand how to properly use this potentially life-saving procedure.
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Lee BK, Jeung KW, Lee HY, Lee SJ, Bae SJ, Lim YD, Moon KS, Heo T, Min YI. Confirmation of intraosseous cannula placement based on pressure measured at the cannula during squeezing the extremity in a piglet model. Resuscitation 2013; 85:143-7. [PMID: 24036195 DOI: 10.1016/j.resuscitation.2013.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 08/30/2013] [Accepted: 09/01/2013] [Indexed: 11/27/2022]
Abstract
AIM OF THE STUDY We sought to assess the reliability of the method using the pressure measured at the intraosseous (IO) cannula while squeezing the involved limb (P(squeezing)) in determining the position of the IO needle and to compare its performance with that of the traditional confirmation method. METHODS Eighty limbs of twenty domestic swine were assigned to one of three conditions regarding the position of the IO needle; correct placement (n=40), incorrect placement in which the IO needle was placed into the subcutaneous space without entering the bone (incorrect-subcutaneous placement, n=20), or incorrect placement in which the IO needle passed entirely through the bone (incorrect-penetrating placement, n=20). A blinded investigator randomly identified the position of the needle by the traditional method or test method using P(squeezing). If P(squeezing) was 80 mmHg or higher, the IO cannula was regarded as incorrectly placed. RESULTS P(squeezing) was higher in incorrect placements (176.0 mmHg (130.0-195.0)) compared with that in correct placements (27.0 mmHg (20.0-34.0)) (p<0.001). The test method correctly identified all 40 placements, but the traditional method was incorrect for one (5%) of 20 correct placements (p=1.000) and 7 (35%) of 20 incorrect placements (p=0.008). In incorrect placements, false positive results occurred mainly in incorrect-penetrating placements. CONCLUSION We suggest that the method using the pressure measured at the IO cannula can be used when there is uncertainty about the position of the IO cannula after determination using traditional methods.
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Affiliation(s)
- Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Hyoung Youn Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Seung Joon Lee
- Department of Emergency Medicine, Myongji Hospital, 697-4, Hwajung-dong, Deokyang-gu, Goyang, Gyeonggi-do, Republic of Korea.
| | - Sei Jong Bae
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Yong Deok Lim
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Kyung Sub Moon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322, Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, Republic of Korea.
| | - Tag Heo
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Yong Il Min
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea.
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Lyon RM, Donald M. Intraosseous access in the prehospital setting-ideal first-line option or best bailout? Resuscitation 2013; 84:405-6. [PMID: 23380288 DOI: 10.1016/j.resuscitation.2013.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 01/28/2013] [Indexed: 11/19/2022]
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Lairet J, Bebarta V, Lairet K, Kacprowicz R, Lawler C, Pitotti R, Bush A, King J. A Comparison of Proximal Tibia, Distal Femur, and Proximal Humerus Infusion Rates Using the EZ-IO Intraosseous Device on the Adult Swine (Sus scrofa) Model. PREHOSP EMERG CARE 2013; 17:280-4. [DOI: 10.3109/10903127.2012.755582] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Julio Lairet
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - Vikhyat Bebarta
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - Kimberly Lairet
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - Robert Kacprowicz
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - Christopher Lawler
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - Rebecca Pitotti
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - Anneke Bush
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
| | - James King
- From the Department of Emergency Medicine, Emory University School of Medicine (JL),
Atlanta, Georgia; the Department of Emergency Medicine, Atlanta VA Medical Center (JL),
Decatur, Georgia; the Department of Emergency Medicine, San Antonio Military Medical Center (VB, CL, RP, JK), Fort Sam Houston,
Texas; John's Creek Surgery Associates (KL),
Suwanee, Georgia; the Department of Emergency Medicine, University of Texas Health Science Center at San Antonio (RK),
San Antonio, Texas; and the Clinical
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Santos D, Carron PN, Yersin B, Pasquier M. EZ-IO(®) intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation 2012; 84:440-5. [PMID: 23160104 DOI: 10.1016/j.resuscitation.2012.11.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/01/2012] [Accepted: 11/09/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Intraosseous access is increasingly recognised as an effective alternative vascular access to peripheral venous access. We aimed to prospectively study the patients receiving prehospital intraosseous access with the EZ-IO(®), and to compare our results with those of the available literature. METHODS Every patient who required an intraosseous access with the EZ-IO from January 1st, 2009 to December 31st, 2011 was included. The main data collected were: age, sex, indication for intraosseous access, localisation of insertion, success rate, drugs and fluids administered, and complications. All published studies concerning the EZ-IO device were systematically searched and reviewed for comparison. RESULTS Fifty-eight patients representing 60 EZ-IO procedures were included. Mean age was 47 years (range 0.5-91), and the success rate was 90%. The main indications were cardiorespiratory arrest (74%), major trauma (12%), and shock (5%). The anterior tibia was the main route. The main drugs administered were adrenaline (epinephrine), atropine and amiodarone. No complications were reported. We identified 30 heterogeneous studies representing 1603 EZ-IO insertions. The patients' characteristics and success rate were similar to our study. Complications were reported in 13 cases (1.3%). CONCLUSION The EZ-IO provides an effective way to achieve vascular access in the pre-hospital setting. Our results were similar to the cumulative results of all studies involving the use of the EZ-IO, and that can be used for comparison for further studies.
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Affiliation(s)
- David Santos
- Emergency Service, Lausanne University Hospital, Switzerland.
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Frisch A, Cammarata S, Mosesso VN, Martin-Gill C. Multivariate analysis of successful intravenous line placement in the prehospital setting. PREHOSP EMERG CARE 2012; 17:46-50. [PMID: 22913329 DOI: 10.3109/10903127.2012.710717] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. Little is known about what factors are associated with successful IV placement, limiting the ability to develop benchmarks for skill maintenance, such as requiring a specific number of IV placements per year. OBJECTIVE We aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts. We hypothesized that IV success is associated with the number of successful IV placements in the preceding year. METHODS We retrospectively studied 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period. Cases involving pediatric patients (age <18 years) and those with incomplete data were excluded. Success of the first IV attempt was identified. Potential predictor variables were collected and analyzed by univariate logistic regression, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider's numbers of total and successful IV attempts in the preceding year. Variables significantly associated with IV success at the p < 0.10 level were included in a multivariate regression model using a p-value of 0.05. RESULTS Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age (p = 0.054), trauma (p = 0.074), IV catheter size (p < 0.001), IV location (p = 0.056), and the number of previous successful IV attempts (p = 0.039), whereas the number of total previous IV attempts was not significantly associated (p = 0.871). In the multivariate logistic regression model, only IV catheter size had a significant association (p < 0.001), with a larger-bore IV catheter size associated with higher success. CONCLUSION In this retrospective study, larger IV catheter size, but not the prehospital providers' previous year's experience, was associated with successful IV placement in adult patients. These data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.
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Affiliation(s)
- Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Abstract
Intraosseous cannulation is an increasingly common means of achieving vascular access for the administration of fluids and medications during the emergent resuscitation of both paediatric and adult patients. Improved tools and techniques for intraosseous vascular access have recently been developed, enabling the healthcare provider to choose from a wide range of devices and insertion sites. Despite its increasing popularity within the adult population, and decades of use in the paediatric population, questions remain regarding the safety and efficacy of intraosseous infusion. Although various potential complications of intraosseous cannulation have been theorized, few serious complications have been reported. This article aims to provide a review of the current literature on intraosseous vascular access, including discussion on the various intraosseous devices currently available in the market, the advantages and disadvantages of intraosseous access compared to conventional vascular access methods, complications of intraosseous cannulation and current recommendations on the use of this approach.
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Affiliation(s)
- James H Paxton
- Department of Emergency Medicine, Detroit Medical Center, Detroit, MI, USA
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Reades R, Studnek JR, Vandeventer S, Garrett J. Intraosseous Versus Intravenous Vascular Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial. Ann Emerg Med 2011; 58:509-16. [DOI: 10.1016/j.annemergmed.2011.07.020] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 07/08/2011] [Accepted: 07/14/2011] [Indexed: 11/26/2022]
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Wampler D, Schwartz D, Shumaker J, Bolleter S, Beckett R, Manifold C. Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients. Am J Emerg Med 2011; 30:1095-9. [PMID: 22030185 DOI: 10.1016/j.ajem.2011.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 07/14/2011] [Accepted: 07/15/2011] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVE Studies on humeral placement of the EZ-IO (Vidacare, Shavano Park, TX, USA) have shown mixed results. We performed a study to determine the first-attempt success rate at humeral placement of the EZ-IO by paramedics among prehospital adult cardiac arrest patients. METHODS A retrospective cohort analysis of data prospectively collected over a 9-month period. Data are a subset extracted from a prehospital cardiac arrest study. The cohort consisted of adult cardiac arrest patients in whom the EZ-IO placement was attempted in the humerus by paramedics. Choice of vascular access was at the discretion of the paramedic; options included tibial or humeral EZ-IO and intravenous. Primary outcome is the percentage of successful placements (stable, flow, without extravasation) on first attempt. Secondary outcomes are overall successful placement, complications, and reason for failure. Data were collected during a post-cardiac arrest interview. RESULTS Humeral intraosseous (IO) access was attempted in 61% (n = 247) of 405 cardiac arrests evaluated with mean age of 63 (±16) years, 58% male. First-attempt successful placement was 91%. Successful placement was 94%, considering the second attempts. In the unsuccessful attempts, 2% reported obesity as the cause, 1% reported stable placement without flow, and 2% reported undocumented causes for failure. There were also 2% reports of successful placement with subsequent dislodgement. CONCLUSIONS The results of this study suggest a high degree of paramedic proficiency in establishment of IO access in the proximal humerus of the out-of-hospital cardiac arrest. Few complications suggest that proximal humeral IO access is a reliable method for vascular access in this patient population.
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Affiliation(s)
- David Wampler
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA.
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Perfusion intraosseuse. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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