1) Intraosseous (IO) access involves inserting a needle into the bone marrow as an alternative route for administering fluids and medications when intravenous access cannot be readily established.
2) IO access was first discovered in the 1920s but saw increased use during World War II and has regained popularity for use in both children and adults.
3) Modern powered IO devices can provide vascular access within 30-90 seconds with a high first-pass success rate of 94-97% making it a valuable option for emergency situations when rapid administration of drugs or fluids is required.
4) Several case studies demonstrate IO access has been successfully used for procedures such as CT imaging with contrast, thrombolysis for STEMI patients
2. Objectives
• Understanding of IO and its use in the ED
• Were IO has come from
• Were we are today
• Focus mainly on use in adults
• Indications, contraindications, downfalls
• Review of literature/notable cases
3. Where the IO has come from…
• Discovered by Drinker &Droan 1920’s
• Published use during World War II
• Mainly for battlefield casualty resuscitation
• Fell out with development of the IV
• Resurgence in paediatrics 1980-2000
• Manual devices
4. Were we are today…
• Becoming popular in adults
• Potentially first line vascular access
• Impact and power driven devices
• Access established within 30-90secs
• 94-97% first-pass success
• Resus Guidelines (Replace ETT)
• Advanced skill for nurses
6. Intraosseous Access
• Immediate alternative to vascular access
• Needle inserted into bone
• Non-collapsible vein
• Infuses into systemic circulation via bone marrow
• Equal predictable drug delivery and
pharmacological effect
• Flow rates 125ml/min
• Hoskins, S. 2011. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation.
Pub Ahead of Print.
7. The IO vs The CVC
• Cheaper ($100 vs $300)
• Multiple insertion sites
• Less training/experience required
• Less complications/infections
• Blood sampling
• First pass success - 90% vs 60%
• Mean procedure time - 2.3 vs 9.9mins.
• Leidel, B. (2009). Is the intraosseous access route and efficacious compared to compared to convention central venous catheterization in adult
patients under resuscitation in the emergency department. A prospective observation study. Patient Saf Surg. 3:24.
8. Indications
• Critically ill – peripherally shut-down
• Immediate need drugs/fluids
• Limited or no vascular access
• Cardiac/respiratory arrest
• Require rapid intubation/sedation
• Behavioral emergencies
• Pre-hospital, disaster, mass casualty situations
9. Contra-Indications
• Fractures/vascular trauma
• Localised infection (cellulitis/osteomyelitis)
• Prosthetic joints near site
• Previous IO attempts
• Osteoporosis
• Inability to identify insertion site
10. Which Site is Best
• Proximal Humerus
– Preferred – quicker delivery
• Tibia – proximal & distal
– Popular – better first pass success
• Sternum
– Inhibits CPR access
• Ong, M. et.al. (2009). An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. American Journal of Emergency
Medicine. 27, 8-15.
•Application of pressure Bags improve flow rates!
12. But doesn’t it hurt???
Insertion:
• Visual Analog score (mean 2.3-2.8)
• Comparable to peripheral IV
Infusion:
• Visual analog score (mean 3.2-3.5)
• Proximal humerus less painful during infusion over tibia
• Insertion of 0.5mg/kg of Lignocaine prior to infusion greatly
reduces pain.
• Philbeck, T. et.al. (2009). Pain management during intraosseous infusion through the proximal humerus. Annals of Emergency Medicine, 54(3):S128.
• Horton,M. & Beamer, C. (2008).Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients.
Pediatric Emergency Care. 24(6), 347-50
13. Downfalls….
• Dwell time 24 hours!
Very rare- but been reported:
• Osteomyelitis (0.6%)
• Extravasation – compartment syndrome (<1%)
• Subcutaneous abscess (0.7%)
• Leakage around insertion site
• Difficulty removing device
• Luck, R. (2010). Intraosseous Access. The Journal of Emergency Medicine. 39(4), 468-475.
•Does it cause an open fracture?
16. Case
• 48 male- Intoxicated – Ped Vs Car
• Presents combative GCS 10- difficult IV
• EZ-IO inserted within 30secs to R humerus
• RSI Roc and Etomidate, Sedated –Fentanyl
+Midaz
• Decision made to use IO for CT trauma series
• Had 155ml contrast/flush inserted over 65secs
• Images reported as excellent quality
• Pt followed up 6/7 no adverse effects noted
18. Case
• 64 male – Inferior STEMI- No CATH Lab
• Difficult access - multiple episodes of VF
• EZ-IO to proximal tibia – bloods taken
• Given 6000U Tenectaplase, 3000u Heparin
• Episode shock-refractory VF given Amiodarone
• 30 mins post Lysis – normalisation of ST-
segments
• Continued Heparin infusion next 12 hours till CVC
inserted
• D/C home 2 days later
20. Case
• 38 female – Massive PPH
• Became hypotensive/tachycardic = circulatory
collapse
• Unable to get IV – IO to humerus
• Given multiple bolus fluids/bloods
• Circulation restored, CVC inserted
• Taken to OR for hysterectomy
• D/C home
21. Massive Transfusion through the IO!
•Burgert, J. (2009). Intraosseous Infusion of Blood Products and Epinephrine in an Adult Patient in Haemorrhagic Shock. AANA Journal.
77(5), 359-363.
22. Case
• 79 female – E.S. Ovarian CA
• 1 hour post jejunostomy tube inserted – in
PACU episode of haematemesis = circulatory
collapse
• IO inserted given blouses of Adrenaline, fluids,
and blood products = resuscitated
• Taken to OR shows L gastric artery bleed
• Died 2 days later in ICU
24. The Results
• RCT – IO Vs IV in OHCA
• 182 patients enrolled
• 64 tibial, 51 humerus, 67 to IV - groups
• Tibial had 91% first pass success compared –
51% for humerus and 43% for IV
•For OHCA tibial IO is advantages and gives excellent vascular
access
26. The Results
• Aim to compared time to established vascular
access wearing CBRN suits
• 16 doctors, 9 nurses randomised to 4
scenarios – manikin based
• No CBRN conditions time to establish access
on average 50secs for IO Vs 70secs for IV
• With CBRN IO group 65secs Vs 104secs for IV.
Intraosseous was shown to be faster in both groups!!
27. Take Home Points
• If you don’t have one – get one!!!
• Simple, easy and effective!
• Train your nurses to use it.
• Consider for first line vascular access!!
