Performance comparison of intraosseous devices and setups for infusion of whole blood in a cadaveric swine bone model.

OBJECTIVES: Intraosseous (IO) access can provide a critical bridge for blood product infusion when peripheral venous access is not obtainable. Successful pressurized IO infusion requires flow rates sufficient to preserve life, but with infusion pressures low enough to avoid clinical complications (e.g., hemolysis, bone damage, fat emboli). However, the optimal method for pressured IO delivery of blood was unknown. METHODS: Three trained physicians infused 500 mL of whole blood through a 15-gauge, 45 mm IO catheter into fresh, high bone density cadaveric swine proximal humeri. Participants applied eight different pressure infusion strategies: (1) gravity, (2) pressure bag, (3) pressure bag actively maintained at or above 300 mmHg, (4) hand pump, (5) hand pump with pressure bag, (6) push-pull with 10 mL syringe, (7) push-pull with 60 mL syringe, and a (8) Manual Rapid Infuser in a randomized within-subjects design (30 trials per method, 240 trials total). The primary outcomes of flow rates, mean and peak pressures, and user ratings were contrasted using ANOVA at p < 0.05. RESULTS: The Manual Rapid Infuser conferred the highest flow rates (199 ± 3 mL/min) and most favorable user ratings, but also the highest mean and peak pressures. Push-pull conferred the next highest flow rates (67 ± 5 mL/min for 60 mL, 56 ± 2 mL/min for 10 mL) and pressures, with intermediate-to-high user ratings. Hand pump flow rates were essentially identical with (45 ± 4 mL/min) or without (44 ± 3 mL/min) pressure bag, with high user ratings without a pressure bag. Pressure bag and gravity methods conferred low flow rates and user ratings. CONCLUSIONS: Some pressured IO infusion methods can achieve flow rates adequate to serve as a resuscitative bridge in the massively hemorrhaged trauma victim, but flow rates and pressures vary greatly across IO pressurized infusion methods. Manual Rapid Infuser and push-pull methods conferred high flow rates but also relatively high pressures, highlighting the importance of using in vivo models in future research to assess the possible clinical complications of using these promising methods. Combined, present findings highlight the importance of studying pressurized IO methods towards preserving the life of the critically injured trauma victim.

Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock.

BACKGROUND: Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known. MATERIALS AND METHODS: Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups. RESULTS: Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism. CONCLUSIONS: Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock.

BACKGROUND: Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized. MATERIALS AND METHODS: Adult female Yorkshire swine (Sus scrofa; n = 36; mean (M): 80 kg, 95% CI: 78-82 kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods (n = 12 each). Flow rates, infusion pressures, vitals, biochemical variables, and pulmonary and renal tissue pathology were contrasted between groups. RESULTS: Flow rates were greater for the Push-Pull strategy than Pressure Bag (96.5 mL/min versus 72.6 mL/min, P = 0.02) or Rapid Infuser (96.5 mL/min versus 60 mL/min, P = 0.002) strategies. The pressures generated during the Push-Pull transfusion (3058 mmHg) were greater than the other strategies (≤360 mmHg). After the observation period, plasma-free hemoglobin levels were higher in the Push-Pull strategy than in the Rapid Infuser (40 mg/dL versus 12 mg/dL, P = 0.02) or Pressure Bag (40 mg/dL versus 12 mg/dL, P = 0.01). Groups did not significantly differ in vitals, biochemical variables, or tissue pathology. CONCLUSIONS: Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.

Tibial Intraosseous Insertion in Pediatric Emergency Care: A Review Based upon Postmortem Computed Tomography.

Objective: The proximal tibia is a recommended and commonly used site for pediatric emergency intraosseous vascular access (IO). During forensic whole body postmortem computed tomography (PMCT), we evaluated accuracy of emergency placement of tibial IO access.Methods: We conducted a retrospective review of 92 state medical examiner cases to assess presence and placement of tibial IO needles. Insertions were classified as successful (needle tip in the medullary portion of the bone) or unsuccessful (all other non-medullary placements) based upon position of the needle tip. Medical records were reviewed for patient age, equipment, and where an insertion was attempted, as well as if IO placement occurred in a prehospital or hospital environment.Results: Thirty-one cases with 42 tibial devices (aged 3 weeks to 16 years, median 4 months) were identified. In 25 insertions (60%), the needle tip was in satisfactory position. In 17 placements (40%), needle tip was unsatisfactory and included tibia perforation (6), tip embedded in the cortex (6), and needle missed the bone (5). In patients older than 6 months, all six placements of a 15-mm needle were successful. In infants age 6 months or younger, 14 placements (56%) were successful and 11 (44%) unsuccessful. The 25-mm IO needle was successfully placed in five of six children older than 6 months. In infants age 6 months or younger, the 25-mm needle was unsuccessfully placed in five of five attempts.Conclusion: In infants 6 months of age or younger, tibial IO needle insertion had a 53% failure rate (non-medullary placement). Failures occur during both prehospital and emergency department care. In infants age 6 months or younger, use of a 25-mm needle should be avoided. Procedures for IO insertion in infants age 6 months or younger should be reviewed and modification considered.

Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest.

INTRODUCTION: Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest. METHODS: This was a structured, retrospective chart review of emergency medical services (EMS) records from three agencies. Data was analyzed from adults who suffered OHCA and received epinephrine through EMS established IV or IO access during the 18-month study period. Per regional EMS protocols, choice of parenteral access type was at the provider's discretion. Non-inferiority analysis was performed comparing the association between first access type attempted and ROSC at time of emergency department arrival. RESULTS: 1310 subjects met inclusion criteria and were included in the analysis. Providers first attempted parenteral access via IV route in 788 (60.15%) subjects. Providers first attempted parenteral access via IO route in 552 (39.85%) subjects. Rates of ROSC at time of ED arrival were 19.67% when IV access was attempted first and 19.92% when IO access was attempted first. An IO first approach was non-inferior to an IV first approach based on the primary end point ROSC at time of emergency department arrival (p=0.01). CONCLUSION: An IO first approach was non-inferior to an IV first approach based on the end point ROSC at time of emergency department arrival.

Evaluation of extremity tissue and bone injury after intraosseous hypertonic saline infusion in proximal tibia and proximal humerus in adult swine.

BACKGROUND: Hypertonic saline (HTS) has been reported as a treatment for sever traumatic brain injury and hemorrhagic shock and current clinical guidelines recommend it. Intraosseous (IO) infusion is often needed in the pre-hospital and combat settings to administer life-saving treatments. However, the safety of IO HTS infusion is not clear. The aim of our study was to evaluate the clinical and histological outcome of HTS IO infusion into the extremity of a large animal model. METHODS: We conducted a randomized comparative study of adult pigs that were infused intraosseously with one of the following solutions: 7.5% HTS, 3% HTS or normal 0.9% isotonic saline. The animals were observed daily for infection, necrosis and gait (5 point Tarlov score) up to 5 days. Five days after infusion, necropsy and histological analysis was performed using a validated scale of tissue necrosis. RESULTS: The mean Tarlov gait scores were similar in all arms and all animals showed a score of 4 (normal ambulation) by day 5. During the 5 day observation period, there were no signs of infection or tissue abnormalities. Histological examinations showed no indication of necrosis, or abnormal bone and muscle healing (p < 0.05). CONCLUSION: We observed regular tissue morphology and normal gait scores over the 5 day observation period. There was an absence of gross tissue necrosis and microscopic ischemia post IO HTS infusion in this swine model. This data confirms the clinical safety of IO HTS infusion and highlights its use as an alternative lifesaving treatment.

The Use of Intraosseous Infusion in the Early Resuscitation of Patients With Extremely Severe Burns.

According to research, shock, the most common complication of extremely severe burns, is also the leading cause of mortality among patients with such burns. The case fatality rate reaches 83.45% when the total burn area exceeds 90%. The American Heart Association in 2020 recommended the intraosseous (IO) access after the peripheral access and prior to the central venous access when venous cannulation is either difficult or delayed. The use and experience with intraosseous infusion in extremely severe burns are still limited. We report efficacy and safety results from 19 burn patients treated with IO infusion between June 2020 and December 2022. In these patients, the mean injury time of burns was 1.55 ± 1.10 hours, the mean burn surface area was 86.24% ± 11.33%, the mean catheterization time was 49.68 ± 10.11 seconds, and the mean emergency retention time was 2.75 ± 1.74 hours, the mean actual fluid supplement amount was 5,533.68 ± 3,077.19 mL, the mean hourly urine volume of the patient was 93.31 ± 60.94 mL, the mean emergency detention time was 4.16 ± 2.97 hours, and the mean duration of hospitalization was 34.50 ± 25.38 days. The results demonstrated a clinically meaningful improvement and higher response rate vs peripheral venous cannulation and an acceptable safety profile in those patients.

Intraosseous administration of thrombolytics for pulmonary embolism.

BACKGROUND: Massive pulmonary embolism is associated with cardiac dysfunction and ischemia, hemodynamic collapse, and significant potential for death. The American College of Chest Physicians and American College of Emergency Physicians each supports thrombolytic administration to hemodynamically unstable patients with acute pulmonary embolism. OBJECTIVES: In the resuscitation of patients with massive pulmonary embolism and obstructive shock, difficulty with vascular access can hinder care. Alternative options may facilitate delivery of thrombolytics and enhance patient management. CASE REPORT: The case presented is a 36-year-old woman with massive pulmonary embolism associated with hemodynamic instability. She was treated with thrombolytics through a tibial intraosseous line. CONCLUSIONS: To the best of our knowledge, this is the first identified case of a patient not in cardiac arrest in whom thrombolytics were administered via an intraosseous line. Similarly, we believe this is also the first reported case of thrombolytics delivered via an intraosseous line for massive pulmonary embolism in the United States.

The Ability of Paramedics to Accurately Locate Correct Anatomical Sites for Intraosseous Needle Insertion.

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.

Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report.

Obtaining adequate vascular access is imperative for effective resuscitative, therapeutic, and diagnostic interventions. The intraosseous (IO) route is indicated when immediate vascular access is needed, and standard central or peripheral intravenous (IV) access is unattainable or would delay therapy in a critical patient. We present a rare case of improper IO line placement in the right proximal tibia of a 30-year-old female involved in a motor vehicle collision, resulting in extravasation of blood products into the surrounding tissue and development of acute compartment syndrome. Emergency Medical Services was unable to obtain IV access in a timely manner, thus a right proximal tibia 45mm IO line was placed, and a unit of whole blood was given with a high-pressure infusor in the field. At the trauma center, the patient's right lower extremity was severely tense and edematous with no palpable right lower extremity pulses and no Doppler signals. Computed tomography revealed the IO catheter extending through both the proximal and distal cortices of the right tibia. Medial and lateral fasciotomy of the right lower extremity was performed in which all four compartments of the right lower leg were released and a significant hematoma was evacuated from the superficial posterior compartment. This case highlights the importance of IO access as a life-saving intervention while also underscoring the need to educate and familiarize pre-hospital and hospital healthcare personnel in delivering IO access so as to mitigate risks and improve outcomes for critically ill patients.

Hacking Intraosseous Infusion Skills Training With 3D Printing: maxSIMIO Drilling System.

Intraosseous (IO) infusion is an alternative way to access the vascular system to administer drugs and fluids, which is particularly helpful when the commonly used peripheral intravenous route is inaccessible. The IO procedure can be done using a drill that involves disinfecting the area, landmarking the insertion point, seating the needle in a firm and stable position in the bone, and then delivering a smooth fluid flush. However, in the current medical training landscape, access to commercially available IO drills such as the Arrow® EZ-IO® Power Driver (EZ-IO; Teleflex, Morrisville, North Carolina, United States) is difficult, especially for rural and remote areas, due to the high costs. Furthermore, the EZ-IO is not rechargeable and does not clearly indicate the remaining battery life, which could potentially put patients at risk during the IO procedure. This technical report aims to address these concerns by describing the development of an alternative, affordable, and reliable IO drilling system for training use: the maxSIMIO Drilling System. This system consists of a cordless and rechargeable IKEA screwdriver which connects to a conventional, hexagon-shaped 3D-printed drill bit needle adapter. Two needle adapters were created: Version A was designed to use a friction-based mechanism to couple the screwdriver with the EZ-IO training needle, while Version B relies on a magnetic mechanism. The major differences between the EZ-IO and the screwdriver are that a) the EZ-IO has only one rotation to advance the cannula while the screwdriver features both directions, b) the EZ-IO is not rechargeable while the screwdriver is, and c) the EZ-IO has a custom needle holder that can fit any EZ-IO training needle size while the screwdriver needs to have a custom needle adapter made to connect to the EZ-IO training needle. Overall, through this exploration, the features of the maxSIMIO Drilling System in comparison to the EZ-IO appear more accessible for IO training. Future considerations for this development include gathering clinical expertise through rigorous testing of this novel system.

Development of Simple and Advanced Adult Proximal Tibia Simulators for a Decentralized Simulation-Based Education Model to Teach Paramedics-in-Training the Intraosseous Infusion Procedure.

Introduction During the COVID-19 pandemic, public health had advised practicing social distancing which led to the temporary shutdown of simulation laboratories or centralized simulation-based education model, shared spaces that healthcare workers such as paramedics use to train on important hands-on clinical skills for the job. One such skill is intraosseous (IO) access and infusion, the delivery of fluids and medication through the marrow or medullary cavity of the bone which provides fast and direct entry into the central venous system. This skill is critical in emergencies when peripheral access is not immediately available. To continue the training of paramedics in life-saving skills like IO infusion in the post-pandemic era, a decentralized simulation-based education (De-SBE) model was proposed. The De-SBE relies on the availability of inexpensive and flexible simulators that can be used by learners outside of the simulation laboratory. However, to date, there is a paucity of simulation design methods that stimulate creativity and ideation, and at the same time, provide evidence of validity for these simulators. Our exploratory research aimed to test a novel approach that combines components of development-related constraints, ideation, and consensus (CIC) approach to develop and provide content validity for simulators to be used in a De-SBE model. Materials and methods The development of the IO simulators was constrained to follow a design-to-cost approach. First, a modified design thinking session was conducted with three informants from paramedicine and medicine to gather ideas for the development of two IO simulators (simple and advanced). Next, to sort through, refine, and generate early evidence of the content validity of the simulators, the initial ideas were integrated into a two-round, modified Delphi process driven by seven informants from paramedicine and medicine. In addition, we surveyed the participants on how well they liked the CIC approach. Results The CIC approach generated a list of mandatory and optional features that could be added to the IO simulators. Specifically, six features (one mandatory and four optional) for the existing simple IO simulator and eight (three mandatories and five optional) for the advanced IO simulators were identified. Following a design-to-cost approach, the features classified as mandatory for the simple and advanced IO simulators were integrated into the final designs to maintain the feasibility of production for training purposes. The surveys with the participants showed that the CIC approach worked well in the group setting by allowing for various perspectives to be shared freely and ending with a list of features for IO simulator designs that could be used in the future. Some improvements to the approach included flagging for potential users to determine what works best concerning the mode of delivery (online or in person), and duration of the stages to allow for more idea generation.  Conclusion The CIC approach led to the manufacturing of simple and advanced IO simulators that would suit a training plan catered to teach the IO access and infusion procedure decentrally to paramedics-in-training. Specifically, they have been designed in a manner that allows them to be made easily accessible to the trainees i.e., low costs and high mobility, and work cohesively with online learning management systems which further facilitates the use of a De-SBE model.

The Development and Initial End-Point User Feedback of a 3D-Printed Adult Proximal Tibia IO Simulator.

Intraosseous infusion (IO) remains an underutilized technique for obtaining vascular access in adults, despite its potentially life-saving benefits in trauma patients. In rural and remote areas, shortage of training equipment and human capacity (i.e., simulators) are the main contributors to the shortage of local training courses aiming at the development and maintenance of IO skills. Specifically, current training equipment options available for trainees include commercially available simulators, which are often expensive, or animal tissues, which lack human anatomical features that are necessary for optimal learning and pose logistical and ethical issues related to practice on live animals. Three-dimensional (3D) printing provides the means to create cost-effective, anatomically correct simulators for practicing IO where existing simulators may be difficult to access, especially in remote areas. This technical report aims to describe the development of maxSIMIO, a 3D-printed adult proximal tibia IO simulator, and present feedback on the design features from a clinical co-design team consisting of 18 end-point users.  Overall, the majority of the feedback was positive and highlighted that the maxSIMIO simulator was helpful for learning and developing the IO technique. The majority of the clinical team responders also agreed that the simulator was more anatomically accurate compared to other simulators they have used in the past. Finally, the survey results indicated that on average, the simulator is acceptable as a training tool. Notable suggestions for improvement included increasing the stability of the individual parts of the model (such as tightening the skin and securing the bones), enhancing the anatomical accuracy of the experience (such as adding a fibula), making the bones harder, increasing the size of the patella, making it more modular (to minimize costs related to maintenance), and improving the anatomical positioning of the knee joint (i.e., slightly bent in the knee joint). In summary, the clinical team, located in rural and remote areas in Canada, found the 3D-printed simulator to be a functional tool for practicing the intraosseous technique. The outcome of this report supports the use of this cost-effective simulator for simulation-based medical education for remote and rural areas anywhere in the world.

Development and Evaluation of a Three-Dimensional-Printed Pediatric Intraosseous Infusion Simulator To Enhance Medical Training.

Vascular access is an essential and rate-limiting step during pediatric resuscitation efforts. Intraosseous (IO) access, an effective resuscitative strategy, remains underutilized in emergency departments. Many medical graduates report never performing the procedure before graduation, and it has been recommended that continuing education and in-servicing programs be implemented to increase the use and familiarity of IO access. The goal of this technical report is to describe the development and evaluation of a three-dimensional (3D)-printed Pediatric IO Infusion Model for simulation-based medical education. The simulator was designed by combining open-source models of a human skeleton and a lower leg surface scan in Blender (Blender Foundation, Amsterdam, Netherlands; www.blender.org), scaled to a pediatric size, and manipulated further using a JavaScript program. Polylactic acid was used to simulate bone while silicone molds were used as skin and soft tissue. Two trainers were produced and evaluated by seven emergency medicine physicians, two family medicine residents, and three medical students. Overall, the simulator was positively received with all participants indicating they would recommend it to assist in the training of others. Suggestions focused on enhancing the anatomical representations of both the skin and bones to enhance the learner experience. The content and outcomes of this report support the use of this simulator as part of simulation-based medical education.

The Development of a Cost-Effective Infant Intraosseous Infusion Simulator for Neonatal Resuscitation Program Training.

Simulation-based medical education (SBME) employs realistic simulators to allow physicians and medical students to learn and practice high acuity, low occurrence (HALO) skills such as the intraosseous (IO) infusion. Previous research was done to develop and evaluate a three-dimensional (3D)-printed adult proximal tibia IO simulator and was rated as a valuable and realistic medical education training tool. This report focuses on implementing this IO simulator for neonatal resuscitation program (NRP) training purposes, as well as to explain the process of redeveloping the previous adult IO simulator and the development of a stand, called the maxSIMbox, to hold the simulators, as well as the tools needed to perform an IO infusion. The feedback provided from stakeholders was helpful, with an emphasis on providing stability to both the infant IO simulator and the maxSIMbox. From this feedback, a functional and cost-effective simulator was developed to practice this HALO skill and is currently being used for NRP training.

[Use of the intraosseous infusion device in the resuscitation ambulances of the Paris fire brigade]. / Dispositif de perfusion intra-osseuse dans les ambulances de réanimation de la brigade de sapeurs-pompiers de Paris.

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

Calf Compartment Syndrome associated with the Use of an Intra-osseous Line in an Adult Patient: A Case Report.

We present a case of a lower limb compartment syndrome associated with the use of an intra-osseous line inserted into the proximal tibia in an adult patient. An unconscious 59-year old male with multiple injuries presented to our Emergency Department after a road traffic accident. Bilateral proximal tibial intra osseous-lines were inserted due to poor venous access. After resuscitation his left leg was noted to be tense and swollen with absent pulses. Acute compartment syndrome was diagnosed both clinically and with compartment pressure measurement. Two incision fasciotomy on his left lower leg was performed. Intra osseous-lines in the proximal tibia are increasingly used in adult patients in the pre-hospital setting by paramedics and emergency physicians. Their use, along with the possible complications of these devices, such as the development of compartment syndrome or osteomyelitis leading to amputation, is well reported in the paediatric literature. To the best of our knowledge, there have not been any previous reports of complications in the adult patient. We present a case of lower leg compartment syndrome developing from the use of an intra-osseous line in the proximal tibia in an adult patient. With the increasing use of intra-osseous lines in adult patients, clinicians should be aware of the possibility of developing compartment syndrome which may lead to disability or amputation in severe cases.

[Leg ischemia complicating the intraosseous infusion of epinephrine for a Djiboutian child]. / Ischémie de jambe secondaire à une perfusion intra-osseuse d'adrénaline chez une enfant djiboutienne.

Intraosseous infusion is increasingly used as an alternative to intravenous infusion. It is recommended for the cardiac arrest of a child in the first instance and after two failed attempts of intravenous infusion in the cardiac arrest of adults. Its rapid use and its low failure rate justify its use in all life-threatening emergencies. It can be used to administer the same treatments as intravenous infusion. It does, nonetheless, present some rare complications, such as acute leg ischemia by extravasation of epinephrine, as we report here. Awareness of these complications is necessary to ensure compliance with the rules of placing this type of infusion.

[Use of the intraosseous access in adult patients in France in 2012]. / Utilisation de la voie intraosseuse chez l'adulte en France en 2012.

OBJECTIVES: To evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS: An email, with an URL to online computerized quiz, was sent to residents and medical doctors who were working, in France, in anesthesiologist units, intensive care units or emergency units. Several questions were asked about theoretical and practical knowledges concerning IO access. RESULTS: After 1359 responses, 396 (29%) practitioners have used an IO kit mainly in case of cardiopulmonary arrest in adults (68%). The insurance of operators in this technique and the rate of physicians who has even put an IO catheter increased with the years of experience of physicians. The reasons given for not using an IO access were no trouble placing a peripheral vein (77%) and unfamiliarity with the equipment and technology (32%). Most of practitioners (753 [55%]) have been trained and 90% (n=265) of untrained doctors believe that training was necessary. The powered system was the most used (71%). CONCLUSION: Only 29% of practitioners have ever used an IO kit. With the new IO kits, a theoretical and practical training is needed to ensure IO kit used.