A Prospective Comparison of Standard Technique, Doppler Ultrasonography, and Pressure Waveform Analysis for Confirming Intraosseous Catheter Placement.

Purpose: Intraosseous (IO) catheters allow healthcare workers to rapidly administer fluids and medications to critically ill patients when intravenous access is inadequate or unable to be obtained. An improperly placed IO catheter can lead to delays in care, as well as serious complications such as limb necrosis. Methods: In this single-center, prospective, observational study, we compared 2 established methods of confirming proper IO catheter placement to a novel pressure waveform analysis technique in which the IO catheter is attached to a standard pressure transducer. Attaching a pressure transducer to a properly placed IO catheter produces a pulsatile waveform. Misplacement of the IO catheter produces a flatline waveform. Results: Of 42 IO catheters, 8 (19%) were incorrectly placed per the waveform analysis technique. Compared to the pressure waveform analysis technique, the standard method and the power Doppler method incorrectly classified 4/8 (50%) and 5/8 (62.5%) of the misplaced catheters, respectively. The standard method had a higher positive predictive value for detecting incorrectly placed IO catheters than the power Doppler method (100% vs 63%, respectively). Blinded reviewers demonstrated better agreement using the pressure waveform analysis technique than using power Doppler (k = 0.77 vs k = 0.58, respectively). Conclusion: The standard and power Doppler ultrasonography techniques identify incorrectly placed IO catheters sub-optimally. The pressure waveform analysis technique is more accurate than the standard of care and has superior interrater agreement compared to the ultrasound method of confirmation. With more than 500 000 IO catheters placed in the United States each year, this novel technique may improve overall IO safety. Trial Registration Number: NCT03908879.

Does an instructional video as a stand-alone tool promote the acquisition of practical clinical skills? A randomised simulation research trial of skills acquisition and short-term retention.

BACKGROUND: The effectiveness of instructional videos as a stand-alone tool for the acquisition of practical skills is yet unknown because instructional videos are usually didactically embedded. Therefore, we evaluated the acquisition of the skill of a humeral intraosseous access via video in comparison to that of a self-study with an additional retention test. METHODS: After ethical approval, we conducted two consecutive studies. Both were designed as randomised controlled two-armed trials with last-year medical students as independent samples at our institutional simulation centre of a tertiary university hospital centre. In Study 1, we randomly assigned 78 participants to two groups: Vid-Self participants watched an instructional video as an intervention, followed by a test, and after seven days did a self-study as a control, followed by a test. Self-Vid ran through the trial in reverse order. In Study 2, we investigated the influence of the sequence of the two teaching methods on learning success in a new sample of 60 participants: Vid-Self watched an instructional video and directly afterward did the self-study followed by a test, whereas Self-Vid ran through that trial in reverse order. In Studies 1 and 2, the primary outcome was the score (worst score = 0, best score = 20) of the test after intervention and control. The secondary outcome in Study 1 was the change in score after seven days. RESULTS: Study 1: The Vid-Self (Participants n = 42) was superior to the Self-Vid (n = 36) (mean score 14.8 vs. 7.7, p < 0.001). After seven days, Self-vid outperformed Vid-Self (mean score 15.9 vs. 12.5, p < 0.001). Study 2: The Vid-Self (n = 30) and Self-Vid (n = 30) scores did not significantly differ (mean 16.5 vs. mean 16.5, p = 0.97). CONCLUSION: An instructional video as a stand-alone tool effectively promotes the acquisition of practical skills. The best results are yielded by a combination of an instructional video and self-study right after each other, irrespective of sequence. TRIAL REGISTRATIONS: ClinicalTrials.gov: NCT05066204 (13/04/2021) (Study 1) and NCT04842357 (04/10/2021) (Study 2).

Finding the most suitable puncture site for intraosseous access in term and preterm neonates: an ultrasound-based anatomical pilot study.

The purpose of this prospective ultrasound-based pilot study was to identify the most suitable tibial puncture site for intraosseous (IO) access in term and preterm neonates, describe tibial dimensions at this site, and provide anatomical landmarks for rapid localization. We measured the tibial dimensions and distances to anatomical landmarks at puncture sites A (proximal: 10 mm distal to the tibial tuberosity; distal: 10 mm proximal to the malleolus medialis) and B (chosen by palpation of the pediatrician), in 40 newborns in four weight groups (< 1000 g; 1000-2000 g, 2000-3000 g, and 3000-4000 g). Sites were rejected if they fell short of the assumed safety distance to the tibial growth plate of 10 mm. If both A and B were rejected, puncture site C was determined sonographically at the maximum tibial diameter while maintaining the safety distance. Puncture site A violated the safety distance in 53% and 85% (proximally and distally, respectively) and puncture site B in 38% and 33%. In newborns weighing 3000-4000 g, at median (IQR), the most suitable puncture site at the proximal tibia was 13.0 mm (12.0-15.8) distal to the tuberosity and 6.0 mm (4.0-8.0) medial to the anterior rim of the tibia. The median (IQR) diameters at this site were 8.3 mm (7.9-9.1) (transverse) and 9.2 mm (8.9-9.8) (anterior-posterior). The diameters increased significantly with increasing weight.  Conclusion: This study adds concise, practical information on the implementation of IO access in neonatal patients: the tibial dimensions in newborns in four different weight groups and initial data on anatomical landmarks to easily locate the IO puncture site. The results may help implement IO access in newborns more safely. What is Known: • Intraosseous access is a feasible option for emergency administration of vital drugs and fluids in newborns undergoing resuscitation when an umbilical venous catheter is impossible to place. • Severe complications of IO access due to malpositioned IO needles have been reported in neonates. What is New: • This study reports the most suitable tibial puncture sites for IO access and the tibial dimensions, in newborns of four weight groups. • The results can help to implement safe IO access in newborns.

Pediatric postmortem CT angiography: validation of vascular access for PMCT angiography in stillbirths, babies and toddlers.

PURPOSE: The use of angiography in postmortem CT angiography (PMCTA) has several advantages. In adults, femoral vascular access is well established. Due to the small and specific anatomy in fetuses and infants, the technique has to be adapted, especially regarding the vascular access. The aim of this study was to evaluate vascular access for pediatric PMCTA (pedPMCTA). MATERIALS AND METHODS: Ten pedPMCTAs were performed in stillbirths, babies, and one toddler. A femoral approach by cannulation of the femoral artery and vein, an umbilical approach by cannulation of the umbilical vessels, and an intraosseous approach by an intraosseous needle were evaluated by handling and resulting imaging. RESULTS: The insertion of a cannula with a size of 18-20 G in the femoral vessels was possible in babies. An umbilical access with peripheral venous cannulas with a size of 14-20 G was feasible in stillbirths and newborns. An intraosseous access is advisable as equal alternative to umbilical and in cases where a femoral access is not possible. The most significant problem with the vascular access is the extravasation of contrast media, but this can be reduced significantly with practice. CONCLUSION: When performing pedPMCTA, an umbilical vascular access is recommended if an umbilical cord with open vessels is still present. Otherwise, a bone marrow access should be preferred in the presence of an arteriovenous shunt or if only the venous system needs to be shown. If that is not the case, the femoral access with the possibility to separate venous and arterial scan should be used.

Attitudes towards the Utilization of Intraosseous Access in Prehospital and Emergency Medicine Nursing Personnel.

Background and Objectives: Insertion of an intraosseous access device enables intravascular access for critically ill patients in a prehospital and emergency department setting even when intravenous access is not possible. The aim of our study was to assess the attitudes of prehospital and emergency department nursing staff towards the utilization of intraosseous access devices. Materials and Methods: We performed quantitative research using a closed-ended structured questionnaire distributed to prehospital unit and associated emergency department nursing staff serving a population of around 200,000 inhabitants. Results: We distributed 140 questionnaires, and 106 were returned and completed. Of these, 69 (65.1%) respondents needed more than three attempts to achieve peripheral intravenous access at least once in the last year and 29 (27.4%) required central venous access because of impossible intravenous access. In the last five years, 8 (7.5%) respondents used endotracheal route for administration of medications. Despite this, only 48 (45.3%) of respondents have ever used the intraosseous route. Also, 79 (74.5%) respondents received at least some training in obtaining IO access; however, 46 (43.4%) answered that education regarding intraosseous access is not sufficient, and 92 (86.8%) answered that they wanted additional training regarding intraosseous access. Conclusions: Prehospital and emergency department nursing staff are aware of the importance of intraosseous access and understand the need for additional education and certification in this field.

Intraosseous contrast administration for emergency stroke CT.

Computed tomography (CT) imaging in acute stroke is an established and fairly widespread approach, but there is no data on applicability of intraosseous (IO) contrast administration in the case of failed intravenous (IV) cannula placement. Here, we present the first case of IO contrast administration for CT imaging in suspected acute stroke providing a dedicated CT examination protocol and analysis of achieved image quality as well as a review of available literature.

Comparison of intravascular access methods applied by nurses wearing personal protective equipment in simulated COVID-19 resuscitation: A randomized crossover simulation trial.

BACKGROUND: Prehospital emergency care of children is challenging. In the era of the COVID-19 pandemic, when medical personnel should use personal protective equipment against aerosol-generating procedures, the efficiency of medical procedures may decrease. The study objective was to evaluate the effectiveness of different intravascular access methods applied by nurses wearing biosafety Level-2 suits in simulated paediatric COVID-19 resuscitation. METHODS: A prospective, randomized, crossover, single-blinded simulation trial was performed. Nursing staff attending Advanced Cardiovascular Life Support courses accredited by the American Heart Association participated in the study. A total of 65 nurses were recruited and randomly assigned to different study groups. They received standard training on intravascular access methods employing distinct devices. The participants wore biosafety Level-2 suits and performed vascular access with the following intraosseous devices: NIO-P, EZ-IO, and Jamshidi needle; intravenous (IV) access was used as a reference method. Both the order of participants and the access methods were random. Each participant performed intravascular access with each of the four methods tested. The effectiveness of the first attempt to obtain intravascular access and the following time parameters were analysed: the time between grasping the intravascular device out of the original packing until infusion line connection. The ease of the procedure was measured with a visual analogue scale (1 - easy; 10 - difficult). RESULTS: The first attempt success rate of intravascular access by using NIO-P and EZ-IO equalled 100% and was statistically significantly higher than that with the Jamshidi needle (80.0%; p = 0.02) and with the IV method (69.2%; p = 0.005). The time required to connect the infusion line varied and amounted to 33 ± 4 s for NIO-P compared to 37 ± 6.7 s for EZ-IO (p<0.001), 43 ± 7 s for Jamshidi (p<0.001), and 98.5 ± 10 s for IV access (p<0.001). The procedure was easiest in the case of NIO-P and EZ-IO (2 ± 1 points; p=1.0) compared with Jamshidi (5 ± 3 points; p<0.001) and IV access (7 ± 2 points; p<0.001). CONCLUSION: The study provides evidence that nurses wearing biosafety Level-2 suits were able to obtain intraosseous access faster and more effectively as compared with IV access during simulated COVID-19 paediatric resuscitation. The most effective method of intravascular access was the NIO-P intraosseous device. Further clinical trials are necessary to confirm the results.

Intraosseous Versus Peripheral Intravenous Access During Out-of-Hospital Cardiac Arrest: a Comparison of 30-Day Survival and Neurological Outcome in the French National Registry.

PURPOSE: To compare intraosseous access with peripheral venous access on adults out-of-hospital cardiac arrest (OHCA) patients' clinical outcomes. METHODS: A national retrospective multicentre study was conducted based on the French National Cardiac Arrest Registry. Comparison of patients (intraosseous vs. peripheral venous access) was conducted before and after a matching using a propensity score. The propensity score included confounding factors: age, time between the call (T0) to epinephrine (to take account of how quickly vascular access was achieved), the aetiology of OHCA, the shock and the patient initial rhythm at MMT arrival. RESULTS: A total of 1576 patients received intraosseous access, and 27,280 received peripheral intravenous access. Before matching, OHCA patients with intraosseous access were less likely to survive at all stages (return of spontaneous circulation (ROSC), 0-day survival and 30-day survival). No significant difference in neurological outcome was observed. After propensity score matching, no significant differences in 30-day survival rates (OR = 0.763 [0.473;1.231]) and neurological outcome (OR = 1.296 [0.973;1.726]) were observed. However, intraosseous patients still showed lower likelihood of short-term survival (ROSC and 0-day survival) even after propensity score matching was implemented. CONCLUSION: The populations we investigated were similar to those of other studies suggesting that intraosseous access is associated with reduced survival and poorer neurological outcome. Our findings suggest that intraosseous access is a comparably effective alternative to peripheral intravenous access for treating OHCA patients on matched populations.

Evaluating practioners' preferences regarding vascular emergency access in newborn infants in the delivery room: a national survey.

BACKGROUND: Venous access during neonatal emergencies in the delivery room (DR) can be accomplished through an umbilical venous catheter (UVC) or an intraosseous (IO) access. Preference of one over the other is unclear. We wanted to evaluate practioners' views. METHODS: An anonymous online questionnaire was circulated to healthcare professionals with different background and experience, all working in neonatal intensive care units in Germany. The web-based survey consisted of 13 questions and data collection was performed using an online tool. RESULTS: We received 502 completed questionnaires, 152 (30%) were from neonatologists, the remainder from residents, fellows and neonatal nurses. For resuscitation of term newborns in the DR 61% of neonatologists vs. 53% of non-neonatologists were in favour of UVC instead of an IO as an emergency access. UVC placement was rated (very) difficult to impossible by 60% of neonatologists and 90% of non-neonatologists (p < 0.05). All respondents cited lack of experience as the main reason for feeling reluctant to place an UVC or IO access, the latter only being taken into consideration in term infants. CONCLUSIONS: UVC placement in the DR is rated more often difficult to use by non-neonatologists than by neonatologists, apparently related to lack of experience. IO access was only considered for resuscitating term infants due to lacking practice and missing approval for birth weights < 3000 g. Frequent training might improve these clinical skills.

Iatrogenic humeral anatomic neck fracture after intraosseous vascular access.

Intraosseous infusion has become a key tool in the resuscitation of critically ill or injured patients, both in pre-hospital settings and in emergency departments. Intraosseous access is obtained through the percutaneous placement of a needle into the medullary space of a bone, thereby allowing access into the systemic venous circulation via the medullary space, which is essential to treat patients in shock, cardiac arrest, airway compromise, or major trauma. This becomes critically important when obtaining conventional intravenous access is difficult or impossible. Few cases of iatrogenic fracture have been reported for intraosseous access in the tibia and no case to-date has been reported of iatrogenic fracture secondary to humeral access. We report a case of a 55-year-old patient being resuscitated emergently with proximal humeral intraosseous infusion for cardiac and respiratory arrest secondary to status epilepticus. After successful resuscitation and removal of the intraosseous cannula, the patient noted new-onset shoulder pain. The patient was ultimately diagnosed with an iatrogenic fracture of the anatomic neck of the humerus through the intraosseous needle tract when the appropriate history was obtained in conjunction with cross-sectional imaging. As the use of intraosseous access expands, such fractures may well be seen more frequently. Intraosseous access is limited to the period of resuscitation and the cannula is often not present at the time of imaging. It is important for radiologists to recognize the findings related to intraosseous access as well as this complication with its characteristic locations and morphology.

Comparison of four different intraosseous access devices during simulated pediatric resuscitation. A randomized crossover manikin trial.

The aim of the study was to compare the success rate, procedure time, and user satisfaction of pediatric NIO™ compared to Pediatric BIG®, EZ-IO®, and Jamshidi intraosseous access devices. This was a randomized, crossover manikin trial with 87 paramedics. The correct location of intraosseous access when using NIO, BIG, EZ-IO, and Jamshidi was varied and was respectively 100, 90, 90, and 90%. The time required to obtain intravascular access (time T1) in the case of NIO, BIG, EZ-IO, and Jamshidi was varied and amounted to 9 s [IQR, 8-12] for NIO, 12 s [IQR, 9-16] for BIG, 13.5 s [IQR, 11-17] for the EZ-IO, and 15 s [IQR, 13-19] for Jamshidi. The paramedics evaluated each device on the subjective ease with which they performed the procedures. The intraosseous device, which proved the easiest to use was NIO, which in the case of CPR received a median rating of 1.5 (IQR, 0.5-1.5) points. CONCLUSION: Our study found that NIO® is superior to BIG®, EZ-IO®, and Jamshidi. NIO® achieved the highest first attempt success rate. NIO® also required the least time to insert and easiest to operate even by novice users. Further study is needed to test our findings in cadavers or human subjects. Based on our findings, NIO® is a promising intraosseous device for use in pediatric resuscitation. What is Known: • Venous access in acutely ill pediatric patients, such as those undergoing cardiopulmonary resuscitation, is needed for prompt administration of drugs and fluids. • Intraosseous access is recommended by American Heart Association and European Resuscitation council if vascular access is not readily obtainable to prevent delay in treatment. What is New: • This simulated pediatric resuscitation compared performance of four commercially available pediatric intraosseous devices in a manikin model. • NIO® outperformed BIG®, EZ-IO®, and Jamshidi in first attempt success rates and time of procedure among novice users.

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

BACKGROUND: The intraosseous (IO) access is an alternative route for vascular access when peripheral intravascular catheterization cannot be obtained. In Denmark the IO access is reported as infrequently trained and used. The aim of this pilot study was to investigate if medical students can obtain competencies in IO access when taught by a modified Walker and Peyton's four-step approach. METHODS: Nineteen students attended a human cadaver course in emergency procedures. A lecture was followed by a workshop. Fifteen students were presented with a case where IO access was indicated and their performance was evaluated by an objective structured clinical examination (OSCE) and rated using a weighted checklist. To evaluate the validity of the checklist, three raters rated performance and Cohen's kappa was performed to assess inter-rater reliability (IRR). To examine the strength of the overall IRR, Randolph's free-marginal multi rater kappa was used. RESULTS: A maximum score of 15 points was obtained by nine (60%) of the participants and two participants (13%) scored 13 points with all three raters. Only one participant failed more than one item on the checklist. The expert rater rated lower with a mean score of 14.2 versus the non-expert raters with mean 14.6 and 14.3. The overall IRR calculated with Randolph's free-marginal multi rater kappa was 0.71. CONCLUSION: The essentials of the IO access procedure can be taught to medical students using a modified version of the Walker and Peyton's four-step approach and the checklist used was found reliable.

[Intramedullary placement of intraosseous cannulas inserted in the preclinical treatment of polytrauma patients : A retrospective, computed tomography-assisted evaluation]. / Intramedulläre Lage von präklinisch angelegten intraossären Zugängen bei polytraumatisierten Patienten : Retrospektive, computertomographisch gestützte Evaluation.

BACKGROUND: Use of intraosseous access to the vascular system is rare in the pre-hospital setting (<1%). However, as patients for which the use of an intraosseous device is indicated are usually in a critical condition, awareness of possible application errors is vital. A survey was performed to evaluate intramedullary needle placement by means of computed axial tomography. METHODS: In the period of 01/01/2011 to 31/12/2015 all multislice-CT trauma scans performed in a trauma center were monitored for intraosseous devices in situ. The placement site, type of intraosseous device and needle deployed, thickness of bone and soft tissues, site for optimum needle placement, and both deviation from gold standard placement and visible complications were also recorded. RESULTS: In 11 out of 982 patients with suspected polytrauma that were studied during the observation period, 13 intraosseous cannulas were found (1.12%). In all cases, the EZ-IO® (Teleflex, P.O. Box 12600, Research Triangle Park, NC 27709, USA) intraosseous vascular access system was used. All applications were placed correctly in the medullary cavity, but none concurred with the current guidelines: The site of the puncture deviated laterally in seven cases, medially in two cases, cranially in four cases, and caudally in two cases. The most common error in all 13 cases was overshooting during needle introduction. CONCLUSION: Even though clinical criteria may suggest correct placement of an intraosseous device, the results of this survey provide evidence that deviations in positioning are common. Placement of the needle too deep can cause complications within the soft tissues or potentially impede intraosseous infusion.

La pose de voie veineuse pédiatrique par les équipes de Smur adultes.

PAEDIATRIC VENOUS ACCESS BEING ESTABLISHED BY ADULT SMUR TEAMS: Paediatric perfusion during pre-hospital care is a major issue in the event of life-threatening emergencies. Access, often restricted, to backup specialising in paediatrics, implies the existence of practices on protocols for the adult mobile emergency and intensive care service (Smur) in partnership with paediatricians. Paediatric perfusion practices were assessed in these teams. The results show the presence of a paediatric protocol in the adult Smur teams is not very common. Nursing practices seem to be evolving towards the recommendations, thanks to technological advances such as the use of the intraosseous device.

Intraosseous Vascular Access in Radiology: Review of Clinical Status.

OBJECTIVE: Paramedics and hospital-based providers occasionally need to place intraosseous devices to obtain vascular access in critically ill patients. Diagnostic radiologists must be prepared for the emergent administration of iodinated contrast media via the intraosseous route, and interventional radiologists should be familiar with the potential clinical uses of such access. CONCLUSION: We present a protocol for the administration of iodinated contrast media through the intraosseous route. We also highlight the clinical and radiologic aspects of intraosseous access.

The Use of Intraosseous Fluid Resuscitation in a Pediatric Patient with Ebola Virus Disease.

BACKGROUND: Vomiting, diarrhea, and severe dehydration are common manifestations of Ebola virus disease (EVD), leading to its high mortality. Mortality is especially high in patients older than 45 years, younger than 5 years, and in pregnant women and their fetuses. The majority of patients with EVD are not able to tolerate the quantities of oral hydration solutions necessary to rehydrate properly. Although some have speculated that IV and intraosseous lines are not practical in the austere, resource-constrained settings of an Ebola treatment unit during an epidemic, it is necessary to provide parenteral fluids and electrolyte replacements to significantly decrease mortality. Due to the inability to spend long periods of time working in hot environments wearing personal protective equipment, it is necessary to maximize the use of rapidly obtainable and safe parenteral access. CASE REPORT: The authors present a case of a 9-month-old patient with EVD in Sierra Leone in whom an intraosseous line was lifesaving. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians respond to international crises, such as the most recent Ebola epidemic in West Africa. It is important for such responders, as well as their responding organizations, to know and understand that intraosseous access is an important and safe modality to use in patients with EVD and in the austere settings often found in disaster settings.

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

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

Adapting the Gamified Educational Networking Online Learning Management System to Test a Decentralized Simulation-Based Education Model to Instruct Paramedics-in-Training on the Emergency Intraosseous Access and Infusion Skill.

Intraosseous (IO) access and infusion is a safe and rapid alternative to intravenous access in obtaining vascular access for administering fluids and drugs. Healthcare professionals, such as primary and advanced care paramedics, use IO access and infusion in emergency circumstances where peripheral intravenous routes are inaccessible. IO access skills require hands-on training, which can be done remotely if the participants have access to simulation, instructions, guidance, and feedback. For the purpose of moving the training outside of the simulation laboratories, we have developed (1) an inexpensive and scalable three-dimensional (3D) printed and silicone-based advanced adult proximal tibial IO access and infusion simulator and (2) a unique learning management system (LMS) for remote simulation-based training. The LMS was built using the Django platform and supports experiential learning by providing access to educational and instructional content (including virtual simulation and serious games), allowing peers to communicate among themselves and with subject-matter experts, provide and receive feedback asynchronously, and engage in learning using gamification elements. The aim of this technical report is to describe the process of development and the final product of the LMS as a research and educational tool to scaffold remote learning of emergency IO skills by paramedics-in-training.

Successful computed tomography angiogram through tibial intraosseous access: a case report.

BACKGROUND: Intraosseous access has been used increasingly with proven efficacy in emergent situations for adults when intravenous access could not be obtained. OBJECTIVE: Our aim was to demonstrate if tibial intraosseous (IO) is an effective route for iodinated contrast administration and pulmonary vasculature visualization. CASE REPORT: We report on an obtunded patient requiring a computed tomography angiogram to help with diagnosis and tibial IO was the only viable access appropriate to withstand the pressure of a computed tomography iodinated contrast load. Tibial IO access was used successfully for administration of iodinated contrast to evaluate for massive pulmonary embolism in an obtunded patient in extremis secondary to cardiovascular instability. CONCLUSIONS: The pulmonary arteries were opacified and demonstrated a high-quality CT angiogram can be done via tibial IO device.

Intraosseous access EZ-IO in a prehospital emergency service.

BACKGROUND: Several scientific and professional associations have made reports and recommendations to regulate the use of intraosseous (IO) access as an alternative to conventional intravenous access (IA) in emergency situations when IA cannot be obtained. It has been well documented that IO access is safe and effective for fluid resuscitation, drug delivery, and blood collection. IO access is attainable in all age groups. OBJECTIVE: The objective of this prospective study was to test the use of a semi-automatic IO infusion system (EZ-IO) as an alternative to vascular access in critical patients treated in a prehospital emergency setting. METHOD: This prospective, cross-sectional study included patients who required immediate peripheral vascular access. This study was performed by reviewing clinical records and through a questionnaire (created by and for nurses who perform the insertion with the EZ-IO). RESULTS: During the study period we identified 107 patients who underwent EZ-IO insertion (114 insertions were performed). Patients were predominantly male (66%) and middle aged (mean age 56 years; range 3-94). Overall, insertion was performed via the proximal tibia (49.4%) distal tibia (25.2%), radius (14.9%), and humerus (10.5%). During the study period, 14 insertions were performed in 2007, 44 in 2008, and 56 in 2009. A majority of patients (50.9%) had medical cardiac arrest, (25.4%) were injured trauma patients, and 12.3% had traumatic cardiac arrest. All patients were transported to a hospital with 2 sites of peripheral vascular access. The first site of access in these patients was IO (100% of cases) and the second site (in 79% of cases) was peripheral intravenous access. All EZ-IO insertions were achieved within 30 seconds and were successful upon the first attempt. CONCLUSION: The use of the EZ-IO provides a quick (100% performed within 30 seconds), easy, and reliable alternative to conventional venous access in critically ill patients. Traditional peripheral venous access requires a minimal preparation that can delay initial treatment in critically ill patients and cause possible interference with resuscitation. The main advantage of using EZ-IO is to obtain secure, immediate, noncollapsible peripheral venous access in critically ill patients. It is possible to obtain a second site of access such as peripheral venous access to administer fluids and drugs, which can improve survival rates.