Description #
There are 2 components to knowing how to perform a procedure: 1) cognitive understanding of the procedure (i.e. indications, contraindications, complications, ordered steps) and 2) the psychomotor coordination and technical skill of performing the procedure itself. The unit will be organized into phases, moving from purely cognitive to progressively more psychomotor skill acquisition.
Phase1: Pre-course reading materials to include indications, contraindications, complications, ordered steps of each procedure.
Phase 2: Instructor demonstrates performance of the procedure. The learner then performs the procedure on a simulation model with supervision and feedback from the instructor.
Phase 3: Human Patient Simulator and Simman simulation scenarios. The learner must now manage the resuscitation of a critically ill patient in parallel with clinical decision-making, team leadership, and appropriate timing of the procedure during real-time patient encounters.
Learning Objectives #
At the end of this unit, learners should be able to perform:
1. Intraosseous infusion on all age groups.
Lecture on Demand #
#
Videos
Article 1 #
Does IO equal IV?
Larry Miller MD, John Kuhn PharmD, Daniel Von Hoff MD
University of Texas Health Science Center – San Antonio 1992 through 1993
Abstract:
Intraosseous administration of medications is increasingly used in pre-hospital emergency medicine when conventional intravenous access to the circulation may be difficult or impossible. Despite the growing popularity of intraosseous infusion, there have been no published data on the pharmacokinetics of intraosseously administered medications in humans. The current study compares the pharmacokinetics of intraosseous (IO) versus intravenous (IV) administration of morphine sulfate (MS) in adults.
The study utilized a randomized crossover design. Each patient served as his or her own control. Patient eligibility was determined by at least one previous attempt at intravenous access in a patient with a confirmed diagnosis of cancer. Both an indwelling intraosseous access device and an intravenous line were inserted into each patient. Patients were randomized to receive a 5 mg bolus of MS, infused IO or IV, followed by an identical dose by the alternate route of administration 24 hours later.
Serial blood samples (5 ml) were taken at baseline, before infusion, and at 13 time points over an 8-hour period post-infusion. Blood samples were analyzed for MS concentration by radioimmunoassay. Pharmacokinetic parameters calculated included maximum plasma concentration (Cmax), time to maximum concentration (Tmax), area under plasma concentration-time curve (AUC0-8), elimination half-life (T 1/2) plasma clearance (CLp), and apparent volume of distribution (Vd). Data were analyzed by analysis of variance.
Full pharmacokinetic data were obtained from 14 of 22 patients. No statistically significant differences were observed between IO and IV administration of MS in adults for Cmax (235 ± 107 ng/ml vs. 289 ± 197 ng/ml, mean ± SD, IO vs. IV, respectively), Tmax (1.3 ± 0.5 min vs. 1.4 ± 0.5 min), AUC0-8 (4372 ± 1785 ng-min/mL vs. 4410 ± 1930 ng-min/mL), T 1/2 or CLp (20.2 ± 7.6 mL/kg/min vs. 20.6 ± 9.4 mL/kg/min). There was a difference in Vd (4.81 ± 1.66 L/kg vs. 3.62 ± 1.41 L/kg, IO vs. IV, p=0.025), thought to be due to a minor depot effect of MS in the bone marrow.
These results provide evidence that drugs administered intraosseously (IO) enter the circulation as rapidly and in the same concentration as those administered intravenously (IV).
Article 2 #
EZ-IO Insertion in 144 Human Cadavers
University of Texas Health Science Center at San Antonio
une 23 through June 27, 2003
Download the article here:
Article 3 #
EZ-IO
Clinical Evaluation of a Novel Intraosseous Device for Adults
Click Here #
#
Article 4
Introduction
“2005 (New): Although many drugs (including lidocaine, epinephrine, atropine, naloxone, and vasopressin) can be absorbed via the trachea, the IV or IO route of administration is preferred…IV or IO drug administration is preferred because it provides more predictable drug delivery and pharmacologic effect…”
(American Heart Association, Currents in Emergency Cardiovascular Care 16, 4 winter 2005-2006.
“… Insertion of a central venous catheter requires interruption of CPR and is associated with several complications…If intravenous access is difficult or impossible, consider the intraosseous route. Although normally considered as an alternative route for vascular access in children, it can also be effective in adults. Intraosseous injection of drugs achieves adequate plasma concentrations in a time comparable with injection through a central venous catheter. The intraosseous route also enables withdrawal of marrow for venous blood gas analysis and measurement of electrolytes and haemoglobin concentration.”
(The European Resuscitation Council Guidelines for Resuscitation 2005
Indications
Fluids and medications
“…Dr. Warren and associates mention that the kinetics of atropine, epinephrine, dopamine, and lidocaine have been studied when administered through the intraosseous route in the laboratory. In the clinical setting, a wide variety of other fluids and drugs have been used, such as saline and glucose containing crystalloid solutions, dextran, protein hydrolysate, whole blood, dexamethasone, heparin, calcium, sodium bicarbonate, isoproterenol, dopamine, dobutamine, phenobarbital, phenytoin, pancuronium, bretylium, and radio-contrast material …”
(“Intraosseous infusions: a flexible option for the adult or child with delayed, difficult, or impossible conventional vascular access”, Kruse JA, et al., 1994)
“…Intraosseous infusion of hypertonic glucose and dopamine is an effective route by which to administer these medications and is potentially useful in emergency situations in which intravascular access is delayed”.
(“Intraosseous infusion of hypertonic glucose and dopamines”, R. Neish, M. G. Macon, J. W. Moore and G. M. Graeber, 1998)
Military (Shock)
“…For fixed-rate infusion, intraosseous crystalloid resuscitation is as efficacious as that delivered by peripheral or central venous routes in reversing hemorrhagic shock…”
(“Comparison of intraosseous, central, and peripheral routes of crystalloid infusion for resuscitation of hemorrhagic shock in a swine model”, Neufeld JD, et al., 1993)
“… The Institute of Medicine has recommended intraosseous (IO) infusion of 7.5% hypertonic saline (HTS) for combat casualties in shock…” (“Hypertonic Saline: Intraosseous Infusion Causes Myonecrosis in a Dehydrated Swine Model of Uncontrolled Hemorrhagic Shock”, Alam H. B. MD et al., 2002)
Mass Casualties and Contaminated patients
“…Current treatment protocols for chemical warfare casualties assume no IV access during the early treatment stages… A spring-driven, trigger-operated intraosseous infusion delivery system may offer an effective solution…”
(“Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: proposed alteration of treatment protocol”, Vardi A, et al., 2001)
“… Resuscitation in the environment of a mass casualty terrorist event is like nothing we now do. New tools like the BIG, which can provide access equivalent to an IV in patients in whom IV starts are extremely difficult, may be crucial to casualty survival….”
(“Intraosseous Emergency Access by Physicians Wearing Full Protective”, Ben-Abraham R., Gur I., Vater Y., and Weinbroum A. A., 2002)
Patients
Adult
“…The highly vascular red marrow of the long bones is gradually replaced by less vascular yellow marrow after about 5 yrs of age. Nevertheless, in addition to marrow cells, fat, and supportive connective tissue, this adult yellow marrow still contains numerous venous sinusoids (5) and frequently allows for modest infusion rates of 20 to 25 mL/min, using typical injection pressures, when cannulated …”
(“Intraosseous infusions: a flexible option for the adult or child with delayed, difficult, or impossible conventional vascular access”, Kruse JA, et al., 1994)
“…In the adult or child with no vascular access and in desperate need of a drug, the potential risks of marrow cannulation may be outweighed by the benefit of administration via the intraosseous route…”
(“Intraosseous infusions: a flexible option for the adult or child with delayed, difficult, or impossible conventional vascular access”, Kruse JA, et al., 1994)
Pediatric
“…Vascular access for the arrested victim is needed for the delivery of resuscitative fluids and medications…. The intravenous or intraosseous route for the delivery of medications is the preferred route…”
(AHA ILCOR, 1997)
“…If intravenous access in the peripheral proximal upper extremity cannot be obtained in three attempts or 90 seconds in a child younger than six years of age, intraosseous vascular access in the proximal tibia or distal femur should be initiated…”
(Pediatric Advanced Life Support: A Review of the AHA Recommendations. Bardella, 1999)
“… There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed…”
(“Long-Term Effects on Tibial Growth After Intraosseous Infusion: A Prospective, Radiographic Analysis”, Claudet, I. MD, MSc; Baunin, C. MD; et al., 2002)
Neonatal
“…Intraosseous infusion is quick, safe, and effective in compromised neonates…”
(“Intraosseous Lines in Preterm and Full Term Neonates”, Ellemunter H., Simma B., Trawöger R., et al., Austria, 1998)
“… Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available…”
(International Guidelines for Neonatal Resuscitation: An Excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science Neonatal Resuscitation pediatric, 2001)
IO similar to IV
“…The intraosseous route of administration was comparable with the central and peripheral intravenous routes for all of the emergency drugs and solutions studied, with equivalent magnitudes of peak effect or drug level and equal or longer durations of action…”
(“Comparison study of intraosseous, central intravenous, and peripheral intravenous infusions of emergency drugs”, J. P. Orlowski, et al., 1990)
“…Virtually all drugs that can be administered via the IV route can be administered by IOI. Fluids and medications such as epinephrine, sodium bicarbonate, calcium chloride, hydroxyethyl starch, 50% dextrose in water and lidocaine have all been shown to have drug levels and peak effects equivalent to the IV route, with an equivalent or longer duration of action. serum concentrations … it is not necessary to adjust drug dosages based on the IOI insertion site…”
(“Intraosseous Infusion”, Brian G. LA Rocco, B.S Henry E.Wang, M.D, 2002)
“…This finding suggests that adjustments in drug dosage may not be required, using various intraosseous locations as an alternative to peripheral intravenous drug therapy…”
(“Pharmacokinetics from multiple intraosseous and peripheral intravenous site injections in normovolemic and hypovolemic pigs”, Warren DW, et al., 1994)
IO and Cutdown
“…In a group of inexperienced paramedic students working on a preserved human cadaver model, intravenous access was gained more rapidly, with a higher success rate, and with fewer complications using the bone injection gun than by the saphenous vein cutdown procedure…”
(“Training pre-hospital personnel in saphenous vein cutdown and adult intraosseous access techniques”, Hubble MW, Trigg DC.)
Proper IO Placement
“…Proper IO placement in the marrow canal can be confirmed by three methods. First, the needle should stand on its own without support. Secondly, after unscrewing the inner trocar from the needle, bone marrow should be able to be aspirated through the needle. Thirdly, a 5-10 ml saline bolus injection should enter with little resistance and without evidence of extravasation; this can be confirmed by carefully observing the calf area for acute swelling or discoloration…”
(“Intraosseous Infusion”, Brian G. LA Rocco, B.S Henry E.Wang, M.D 2002)
Laboratory Samples
“… Aspirates of the bone marrow obtained before starting drug or fluid administration may be analyzed for blood-chemistry values, Paco2, pH, and hemoglobin concentrations, and can be used to type and crossmatch a patient for blood transfusion …”
(“Intraosseous infusions: a flexible option for the adult or child with delayed, difficult, or impossible conventional vascular access”, Kruse JA, et al., 1994)
“…Blood aspirated from the IOI site may be used for certain laboratory analyses. Hurren demonstrated that when comparing blood drawn from a venous site to blood from an IO site, hemoglobin, hematocrit, sodium, urea, creatinine, and calcium levels were “sufficiently similar to be clinically useful.” However, potassium and glucose levels were significantly variable in the bone marrow sample as compared to the venous sample…” (“Intraosseous Infusion”, Brian G. LA Rocco, B.S Henry E.Wang, M.D 2002)
Complications
“The risks and complications of IOI are rare and outweighed by the benefits of immediate vascular access for administration of fluids or medications. Extravasation of fluid is the most common complication; this may occur from a misplaced needle, multiple attempts in the same bone, or from movement of the needle enlarging the penetration site This is irrelevant for the BIG but very relevant for manual device… Osteomyelitis is a rare complication, occurring in 0.6% of this occurs most frequently with prolonged needle placement, pre-existing bacteremia and the use of hypertonic fluids. Promptly replacing the IO needle with conventional peripheral or central venous access may minimize these complications.
The theoretical complication of injury to the epiphyseal growth plate has not been supported by long-term prospective radiographic analyses of tibial length. IOI has not been demonstrated to cause histologic damage to metaphyseal cell lines or morphologic damage to the growth plate of rabbits. (“Intraosseous Infusion”, Brian G. LA Rocco, B.S Henry E.Wang, M.D 2002)
Rev. 4.2006
Article 5 #
The Use of a Powered Device for Intraosseous Drug and Fluid Administration in a National EMS: A 4-Year Experience
Article 6 #
The Use of a Powered Device for Intraosseous Drug and Fluid Administration in a National EMS: A 4-Year Experience
Download the article here: