Pediatric emergency intravenous access. Evaluation of a protocol

Pediatric trauma. Anesthesia management

Prevention of childhood injury remains the cornerstone of reducing the number of children who present for post-traumatic surgical intervention. Beyond prevention, the next best step is the accurate diagnosis and treatment of traumatic injury. Anesthesiologists contribute to this step by providing timely resuscitation and optimal care to avoid secondary injury. This article classifies trauma in children into different categories depending on the location of the injury. Trauma, of course, is rarely focal, and is often a multisystem entity. With knowledge in management for each subset of trauma, one may be efficient in prioritizing injury and have a good understanding of the appropriate management of the pediatric patient with multiple traumatic injuries.

Intraosseous infusion and pulmonary fat embolism

OBJECTIVES: To determine the incidence of pulmonary fat embolism after the intraosseous (IO) infusion of normal saline and drugs and to determine whether pulmonary capillary blood is a predictor of lung fat embolism. DESIGN: A randomized, prospective, animal study. SETTING: Animal research laboratory of a university hospital. SUBJECTS: Twenty-eight mixed breed piglets (average weight 30.9 kg). Interventions and Methods: Animals were anesthetized, intubated, mechanically ventilated, and instrumented. IO needles were placed in the tibial bone. Animals were assigned to one of four groups: Group 1 received fluid (20 mL/kg) under 300 mm Hg pressure (n = 6); group 2 received fluid (20 mL/kg) at free flow under gravity (n = 6); group 3 received 100 mL of fluid over 20 mins (n = 8); and group 4 received 100 mL of fluid over 7 mins (n = 8). MEASUREMENTS AND MAIN RESULTS: Buffy coat samples were obtained from pulmonary arterial catheter in the occluded position at baseline, after IO needle placement, and at the end of infusion. Lung specimens (both upper and lower lobes) were obtained at the end of the infusion. Specimens were stained with oil red O and graded for fat emboli by a pathologist blinded to experimental conditions. Fat emboli (one to three emboli per high power field) were found in about 30% of the lung specimens. The difference in number of fat emboli between groups was not statistically significant. Buffy coat stains yielded fat emboli, which were distributed sporadically in all groups. CONCLUSION: Fat embolism is common; however, the method of IO fluid administration does not influence the number of emboli. Our study therefore implies that the risk of fat embolization is of concern, but its clinical relevance is unclear. Until the clinical significance of pulmonary fat emboli and the prevalence of fat emboli syndrome are delineated more precisely, the IO route is an effective but not necessarily safe route for delivery of fluids and drugs.

Corpus cavernosum as an alternative means of intravenous access in the emergency setting

BACKGROUND

The present study was designed to investigate the feasibility of using the corpus cavernosum as an alternative means of intravenous access in the emergency setting.

METHODS

The feasibility of achieving the infusion flow rates was first ascertained using direct intracavernous infusion of normal saline. The effect of atropine and adrenaline when given via this route was then studied. Hypovolaemic shock was then induced in dogs who were then actively resuscitated via this route using normal saline, Haemaccel and whole blood.

RESULTS

Infusion flow rates were achieved for normal saline of 32.3, 50.3 and 67.3 mL per min at 100, 200 and 300 mmHg pressure, respectively. The peak effects of atropine and adrenaline via this route were seen at approximately 1 min after injection. Resuscitation using this method was uniformly successful in all dogs via the corpus cavernosum, with all reaching or exceeding their premorbid central venous pressure (CVP), and approaching or reaching their premorbid mean arterial pressure (MAP). In comparison the control dog's CVP and MAP did not rise during the period of observation after it was bled.

CONCLUSIONS

The corpus cavernosum is a practical alternative means of intravenous access in the emergency setting in the dog model.

Intraosseous access using butterfly needle

Butterfly needle (18 G) was used for intraosseous administration of fluids and drugs in 22 children with shock. All except one patient could be stabilized successfully. Fifteen children had severe dehydration because of diarrhoea. The intraosseous route needs to be popularized as an option for rehydration in areas, where diarrhoeal dehydration continues to be an important cause of child mortality.

[Retrospective study of 32 cases of intraosseous perfusion]

BACKGROUND

We studied all intraosseous infusions performed between 1994 and 1997 by the pediatric intensive care unit and by the pre-hospital emergency medical staff in the Hôpital d'Enfants, Toulouse, France.

POPULATION AND METHODS

We report 32 cases of intraosseous infusions in 30 children aged 2 weeks to 9 years.

RESULTS

In our population, such a technique has been used in about 60% of all cardiopulmonary arrest, drowning or traffic accident cases. Intraosseous infusion was successful in all cases, on the first attempt in more than 80% of cases. Nine children recovered without any sequelae. No major complications have been observed.

CONCLUSIONS

Intraosseous infusion is safe, rapid and effective. It is an essential alternative route in pediatric resuscitation when no other venous access can be performed quickly. An effort must be made on behalf of its diffusion and teaching.

[Intraosseous infusion in children]

OBJECTIVE

To assess the benefits and drawbacks of intraosseous infusion (IOI) for emergency therapy in children.

STUDY DESIGN

Retrospective, non comparative study of IOI carried out between January 1994 and June 1998.

PATIENTS

Forty-one children requiring without delay IOI either in the emergency medical ambulance or the emergency admission and intensive therapy units.

METHODS

The tibia was punctured by paediatricians either with Mallarmé's trocars in 1994 or Cook Critical Care trocars from 1995 on.

RESULTS

Overall, 46 IOI have been carried out in 41 children with a median age of 18 months (range: 8 days-9 years). The main indications for IOI were the management of near drowning, road traffic accidents and cardiopulmonary resuscitation. Complications included one articular puncture and nine subcutaneous extravasations, requiring the puncture of the other limb in five cases.

CONCLUSION

IOI is an easy technique for vascular access. It is indicated in emergency cases when, after a delay of five minutes, other techniques have failed.

Intranasal midazolam in patients with status epilepticus

The patient in status epilepticus presents many challenges to the emergency physician. IV access is frequently difficult to achieve, and prolonged attempts at access can jeopardize the patient and endanger the caregiver. We present two cases in which the administration of intranasal midazolam appeared to successfully terminate status epilepticus. No adverse effects were noted. Studies are needed to clarify the safety, optimal dosing, and clinical utility of this treatment modality.

Intraosseous resuscitation of hemorrhagic shock in a pediatric animal model using a low sodium hypertonic fluid

OBJECTIVE

To study the efficacy of a low sodium hypertonic resuscitation fluid for resuscitation of severe hemorrhage in a pediatric animal, using the intraosseous route.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University physiology laboratory.

SUBJECTS

Seventeen immature (6- to 9-wk-old) piglets, weighing 10.6 +/- 0.4 kg, were studied under anesthesia.

INTERVENTIONS

A new 2400 mosm/L hypertonic fluid, "Isosal" was formulated with reduced (3.45%) sodium content compared with a 2400-mosm/L (7.5%) hypertonic saline solution. This formulation was accomplished by substituting glucose and mixed amino acids for sodium. Piglets were subjected to 1 hr of hemorrhage, reducing the cardiac output to 50% of baseline value. Resuscitation was carried out through the intraosseous route with an initial 6 mL/kg bolus of either hypertonic saline, Isosal, or lactated Ringer's solution. After the initial bolus, additional test fluid was given to maintain the cardiac output at baseline value for a 2-hr period.

MEASUREMENTS AND MAIN RESULTS

Total resuscitation volumes, hemodynamic variables, and electrolytes were measured. Intraosseous vascular access was easily established in all animals, and fluid resuscitation was carried out effectively through this route. Resuscitation volumes were significantly lower for both of the hypertonic fluids (12.7 +/- 1.2 mL/kg for hypertonic saline, and 12.5 +/- 1.7 mL/kg for Isosal solution) compared with lactated Ringer's solution (75.3 +/- 11.6 mL/kg) (p = .01). Both hypertonic saline and Isosal solution resulted in an immediate supranormal response in cardiac output that lasted 20 mins. In contrast, when lactated Ringer's solution was used, multiple boluses were required over a 20-min period to normalize cardiac output. Serum sodium was significantly higher in the hypertonic saline group compared with the Isosal or lactated Ringer's groups (p = .001).

CONCLUSIONS

Isosal solution was as effective as hypertonic saline in "small volume" resuscitation of severe hemorrhagic shock in a pediatric animal model through the intraosseous route, and produced significantly less hypernatremia when compared with hypertonic saline.

Hematologic safety of intraosseous blood transfusion in a swine model of pediatric hemorrhagic hypovolemia

OBJECTIVE

To assess the risk of hemolysis, disseminated intravascular coagulation (DIC), or fat embolism syndrome (FES) with pressurized intraosseous (IO) blood transfusion following hemorrhage.

METHODS

A controlled, repeated-measures, randomized animal study with blinded pathologic evaluations was conducted. Sixteen pentobarbital-anesthetized, instrumented immature swine underwent a 20-mL/kg hemorrhage into citrate-phosphate-dextrose bags, then received autologous blood transfusion via a 16-ga i.v. catheter (eight), or via a 15-ga IO needle in the proximal tibia (eight) under maximal manual pressure using a 30-mL syringe. At baseline and at one hour and 48 hours posttransfusion, blood samples were assayed for hemoglobin (Hb), schistocytes, free Hb in plasma, bilirubin, lactate dehydrogenase, platelets, fibrinogen, and alveolar-arteriolar O2 gradient. Lung sections were examined for inflammation after hematoxylin/eosin stain, and for fat emboli after oil red-O-stain. Kidney sections were examined for inflammation using hematoxylin/eosin stain.

RESULTS

Though the IO transfusion rate of 21 +/- 6 mL/min was slower than the i.v. rate of 35 +/- 5 mL/min (p = 0.0012), all the animals returned to baseline blood pressure within 15 minutes and survived. The presence of schistocytes and mildly elevated free Hb in plasma was noted in both groups at baseline and each time period, and was presumed to be due to sampling from the arterial catheter. All other laboratory values remained within normal limits and without intergroup differences at any time period. No fat embolus was noted, and all lung and kidney specimens were free of inflammation.

CONCLUSIONS

In this model, pressurized IO blood transfusion appears to be hematologically safe, i.e., without risk of appreciable hemolysis, DIC, or FES.

Mastering pediatric cardiopulmonary resuscitation

Premature and unexpected death, especially in children, is tragic and very unacceptable. Effective treatments for sudden death of pediatric patients continue to emerge. Modern cardiopulmonary resuscitation function began with the widespread introduction of closed-chest cardiac massage in 1960; however, despite 35 years of research and refinement, more than 90% of children who receive cardiopulmonary resuscitation do not survive. This article summarizes and expands on current treatment concepts for pediatric sudden death. Emphasis is placed on procedures and techniques that likely are accessible in most medical centers caring for critically ill and injured children.

Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration

Difficulties and delays in establishing intravenous access are not uncommon in emergency situations in pediatrics. Alternatives to venous cannulation exist, including intraosseous access, intratracheal drug administration, sublingual and intralingual injection, the intrapenile route, and intracardiac injection. Each of these emergency alternatives to intravenous access is discussed from the historical, technical, utilitarian, and risk-benefit aspects. It is concluded that the intraosseous effective alternative to intravenous access in emergency situations.

Are laboratory values in bone marrow aspirate predictable for venous blood in paediatric patients?

In an emergency situation, early laboratory results are important, but often difficult to obtain. If venous access cannot be established, the intraosseous route may be used as an alternative. This study investigated the predictive value of bone marrow aspirate in performing laboratory studies. Thirty children underwent general anaesthesia for bone marrow aspiration (iliac crest) for oncologic or haematologic reasons. The aspirate and a peripheral venous blood sample, which was obtained simultaneously, were subjected to different laboratory tests and the results were compared by means of confidence interval analyses of the individual ratios of venous/bone marrow values. Based on these analyses, a high predictability of bone marrow values were found for haemoglobin, sodium, chloride, glucose, bilirubin, urea, creatinine, pH, and standard bicarbonate. Moderate, but clinically useful predictability was found for haematocrit, potassium, and total protein, while bone marrow values of alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, PCO2, PO2, thrombocytes and leukocytes were systematically different from values in venous blood. Our data suggest that the intraosseous route is not only an important emergency alternative to intravenous access for administering fluids and drugs but may also serve as a reliable alternative for obtaining initial diagnostic laboratory studies when intravascular access is not obtainable.

Rectal diazepam for prehospital pediatric status epilepticus

STUDY OBJECTIVES

To compare the feasibility, effectiveness, and safety of rectal diazepam and intravenous diazepam in the treatment of pediatric prehospital status epilepticus.

DESIGN AND SETTING

Retrospective analysis of a 30-month consecutive sample of ambulance-transported children in a large urban emergency medical service region.

TYPE OF PARTICIPANTS

Study group included 324 patients with seizure who were less than 18 years of age; 36 had status epilepticus, of whom 16 received rectal diazepam and 15 received IV diazepam.

INTERVENTIONS

For children with status epilepticus, paramedics administered the 5-mg/mL IV solution of diazepam by one of two routes: rectally either through a 5F feeding tube with an attached syringe or by lubricated tuberculin syringe inserted 4 to 5 cm into the rectum at a one-time dose of 0.2 to 0.5 mg/kg or intravenously using a one-time dose of 0.1 to 0.3 mg/kg. Cardiopulmonary status was carefully monitored in the field and emergency department.

MEASUREMENTS AND MAIN RESULTS

Thirteen of 16 children (81%) who received rectal diazepam stopped seizing after a single dose ranging from 0.16 to 0.57 mg/kg. Convulsions recurred before arrival at the ED in four of the 13 (30.8%). All of three patients who did not respond to rectal diazepam initially were 3 to 5 years old and had serious underlying comorbidity; two required endotracheal intubation in the ED and multiple anticonvulsants to terminate the seizure. No child treated with rectal diazepam required prehospital endotracheal intubation. All children who received IV diazepam stopped seizing after one dose ranging from 0.04 to 0.33 mg/kg. Convulsions recurred before arrival at the ED in nine of 15 children (60%); two required prehospital endotracheal intubation for profound respiratory depression.

CONCLUSION

Rectal diazepam is a simple, effective, and safe method of prehospital management of pediatric status epilepticus. Compared with IV diazepam, rectal diazepam is easier to administer, especially in infants and toddlers; is equally efficacious; and is less likely to produce respiratory depression. Although respiratory depression is rare with rectal diazepam, prehospital personnel must be prepared to provide definitive respiratory support. Short duration of action is an important limitation of both treatments.

Transport and stabilization of the pediatric trauma patient

The incidence of pediatric trauma continues to increase, presenting at almost every emergency department. Life-threatening injuries need to be cared for immediately, in whatever institution the patient presents. For severely injured children, optimal care is ultimately provided at specialized trauma centers. Physicians caring for trauma patients in less specialized institutions must be aware of who to transfer to a trauma center. Effective stabilization and timely, safe transport are vital to reduce further injury.

Evaluation, treatment, and transport of pediatric patients with shock

Early recognition and correct treatment of shock remain the most important keys to preventing the death and disability frequently caused by this condition in children. The pediatrician plays a vital role in this process and in referral of the patient for transport to tertiary care centers, where shock is best managed. The transport environment creates special challenges in initial stabilization and ongoing treatment of shock. Discussion centers on clinical clues to recognition, on simple measures available to increase tissue oxygenation, and on the issues of pretransport and transport treatment. Support of airway and breathing, vascular access, and correct fluid therapy remain the cornerstones of successful treatment.

Comparison of fluid infusion rates among peripheral intravenous and humerus, femur, malleolus, and tibial intraosseous sites in normovolemic and hypovolemic piglets

STUDY OBJECTIVES

To compare infusion rates from various intraosseous sites (tibial, medial malleolar, distal femoral, and humeral) and at a peripheral IV site under gravity and pressure flow in normovolemic and hypovolemic states.

DESIGN AND SETTING

A piglet model was used to assess rates of infusion under varying conditions in a university hospital animal laboratory. Analysis of variance was used to evaluate site differences.

PARTICIPANTS

Twenty-three Yorkshire-Landrace mix pigs (weight, 12 to 23 kg) were studied.

INTERVENTIONS

Animals were anesthetized and intubated before cannulation with 18-gauge bone marrow needles at intraosseous sites and 22-gauge Teflon catheters in peripheral vessels. Infusion rates under gravity and 300 mm Hg pressure were determined. Infusion rates under similar conditions were repeated in hypovolemic animals with acute bleeding of 25 mL/kg.

MEASUREMENTS AND MAIN RESULTS

Mean infusion rates (mL/min) for gravity versus 300 mm Hg pressure in normovolemic pigs were 13.1 versus 40.9 for peripheral IV, 11.1 versus 41.3 for humerus, 9.3 versus 29.5 for femur, 8.2 versus 24.1 for malleolus, and 4.3 versus 17.0 for tibia. Hypovolemia resulted in average decreased rates of 32%. Infusion rates were significantly different between sites and between normovolemia and hypovolemia (P = .0001).

CONCLUSION

Intravenous access is the most efficacious method of acute volume replacement. Intraosseous sites differ in the infusion rates obtained--descending order is humerus, femur, malleolus, and tibia, but each is a reasonable alternative for short-term vascular access.

[Intraosseous infusions in pediatric life-threatening emergencies]

As the bone marrow is a vascular tissue which cannot collapse, it may be used as a vascular access to treat life-threatening emergencies especially in children. Two cases reported here underline the value of this life-saving procedure. Both children were 9 months old, and were admitted for severe dehydration, having lost 15 and 10% of body weight respectively. All attempts to set up an intravenous infusion in a peripheral vein failed in both. The fontanelles were closed, and the central veins (internal jugular and subclavian veins) easily accessible, however collapsed. Intraosseous infusion was decided as a last ditch procedure. A 15-gauge Mallarmé's trocar was inserted at the proximal end of the tibia. In both children, this allowed rehydration to be carried out, and, in the second child, anticonvulsive and antibiotic therapy to be started. The intraosseous line was replaced, in the first child, at the third hour, by a conventional infusion line, set up by denudation, and in the second one, by a subclavian line. This technique has few contra-indications, and the complication rate is low. However, this technique should remain limited to a few indications only.

The effects of intraosseous infusion on the growth plate in a nestling rabbit model

STUDY OBJECTIVE

The objective of this study was to test the hypothesis that saline or bicarbonate infusion does not damage the growth plate in a nestling rabbit model.

SETTING

Animal laboratory.

DESIGN

In this prospective study, 22 tibias from nestling rabbits were randomized into control, puncture-only, physiologic saline, or bicarbonate infusion groups and killed three and five days after treatment for evaluation of injury.

MEASUREMENTS

Bone injury was evaluated by microradiograph and by decalcified and undecalcified histology.

RESULTS

Radiographs demonstrated loss of trabecular (ie, calcified) bone after infusion of both saline and bicarbonate solutions. Although no histologic damage to the cell lines of the growth plate was seen, newly formed bone trabeculae were seen in both infusion groups, suggesting injury and repair at sites of infusion. These findings were absent in control and puncture-only groups. No histologic or radiographic differences were seen between saline and bicarbonate infusions.

CONCLUSION

The nestling rabbit provides a good animal model for evaluating the effects of intraosseous infusion on growing long bones and cartilage. Saline and bicarbonate infusions did not damage morphologically the metaphyseal growth plate but did cause loss of bone trabeculae that support the growth plate. The injury appeared to be repaired rapidly in these nestling rabbits.

Typing and screening of blood from intraosseous access

STUDY OBJECTIVE

To determine if intramedullary aspirate from intraosseous needle placement can be used as a source for evaluating blood compatibility.

DESIGN

A prospective, nonrandomized, crossover study.

SETTING/PARTICIPANTS

Patients admitted to the hematology/oncology service undergoing bone marrow aspiration for medical purposes.

INTERVENTIONS

Patients had simultaneous samples of bone marrow aspiration from the posterior iliac crest and peripheral venous blood drawn and sent for typing and screening.

MEASUREMENTS AND MAIN RESULTS

The paired samples were evaluated for ABO and Rh typing as well as the presence of human leukocyte activity by evaluating the reaction strength between the marrow and venous samples.

RESULTS

No differences were seen in the reaction strength between the paired samples in any subjects for ABO and Rh typing (P = .90, yielding beta = .0523). In addition, human leukocyte activity was detected in both the marrow and venous samples in one patient.

CONCLUSION

Bone marrow aspirates following intraosseous infusion can be used for accurate and reliable typing and screening of blood.

Controversies in cardiopulmonary resuscitation: pediatric considerations

This article addresses some therapeutic controversies concerning medications that may be needed during advanced pediatric life support (APLS) and the routes of administration that may be selected. The controversies that are discussed include the appropriateness and selection of various routes for drug administration during APLS; the determination of whether epinephrine hydrochloride is the adrenergic agent of choice for APLS and its appropriate dose; treatment of acidosis associated with a cardiopulmonary arrest; recommendations for atropine sulfate doses; and the role, if any, of calcium in APLS. Background information differentiating pediatric from adult cardiopulmonary arrest is presented to enable the reader to have a better understanding of the specific needs of children during this life-threatening emergency. The article also presents an overview of various drugs used for APLS and a table of their typically recommended doses and routes of administration.

A prehospital model of intraosseous infusion

STUDY OBJECTIVE

Before the implementation of an intraosseous infusion protocol by the City of Pittsburgh paramedics, we undertook a study to compare the establishment of a simulated intraosseous infusion in three different prehospital settings. The purpose of this study was to determine the time to establish an intraosseous infusion and the success rate at the scene and en route to the hospital using this model.

DESIGN

Prospective study.

SETTING

Three prehospital scenarios: classroom (scene); a medic unit traveling at 25 mph and making slow, steady turns (turns); and a medic unit traveling at 30 to 35 mph with sudden stops and starts (stop and go).

TYPE OF PARTICIPANTS

Paramedics and emergency medicine residents.

MEASUREMENTS AND MAIN RESULTS

Successful placement of the IO needle was confirmed by the aspiration of marrow or the free flow of 5 to 10 mL of normal saline without extravasation into the surrounding tissue. The procedure was timed from skin entry to establishment of infusion. All participants were successful in establishing IO infusion, with 84.8% of infusions achieved in less than one minute in all settings. The scene had somewhat shorter mean and median times and a higher first-attempt success rate, but the differences between scenarios were not significant.

CONCLUSION

Using a simulated model, IO access can be established successfully in the prehospital setting. The minimal time delay in establishing IO infusion may make it an appropriate technique for use at the scene or en route to the hospital.

Effect of intraosseous saline infusion on hematologic parameters

STUDY OBJECTIVE

To examine the effects of intraosseous saline infusion on hematologic parameters.

DESIGN AND SETTING

Eight New Zealand White rabbits were anesthetized with intramuscular ketamine. An initial blood sample was withdrawn from a earlobe vein on induction of anesthesia. An 18-gauge intraosseous needle was then inserted into the rabbit's proximal tibia, and 10 mL/kg of normal saline was infused over one minute. Two additional blood samples were obtained 15 and 30 minutes after the intraosseous infusion.

MEASUREMENTS

Complete blood counts were performed on the blood samples.

RESULTS

Significant differences were found in monocytes, basophils, and nucleated RBCs from samples drawn before and after intraosseous infusion. The microscopic examination of the peripheral blood smear revealed an increase in the number of burr cells, schistocytes, and polychromasia in the postinfusion samples.

CONCLUSION

We advocate caution in the interpretation of hematologic studies performed on blood samples obtained shortly after an intraosseous infusion.

Intraosseous infusions: an important but forgotten method of vascular access

Patients with malignancies or other prolonged illnesses such as acquired immune deficiency syndrome, require long-term vascular access. Unfortunately, currently available technologies which access the vascular system, such as intravenous catheters (external or implanted ports), have frequent complications including clotting and infection which limit their long-term usefulness. An important but forgotten method to access the central venous system is through the intraosseous route. This review summarizes past experience with the intraosseous route of access to the central venous system as well as describes a new device which might eventually make intraosseous access more convenient for the patient. It is anticipated this forgotten method of vascular access will be used more frequently in patients who have exhausted conventional venous access systems.

Comparison of intraosseous versus intravenous loading of phenytoin in pigs and effect on bone marrow

Much recent literature supports the resurgence of the intraosseous route of access in pediatrics. Intraosseous lines provide a timely noncollapsable route to the circulation in medical or traumatic emergencies when intravenous access is not possible. There has been no controlled study comparing intravenous and intraosseous loading of phenytoin. A 15 mg/kg dose of phenytoin was administered over 15 minutes to pigs by either the intravenous (n = 6) or tibial intraosseous route (n = 6). Femoral artery blood samples were drawn every 5 minutes for 35 minutes after initiation of infusion to determine phenytoin levels. There was no statistical difference between the two groups using analysis of variance repeated measures (P = .160). Microscopic examination of the cortex and marrow at the intraosseous site in these pigs was normal 5 weeks postinfusion. The authors conclude that the intraosseous route is an effective alternative to intravenous loading of phenytoin without permanent damage to the marrow.

A child-oriented emergency medical services system

Although the principles of emergency care may be relatively easy to state, it is their promulgation that is so difficult. The development of EMS-C is the challenge. How do we take these principles of preserving children's lives and translate them into services for everyone who needs them? How do we organize a large, diverse health care system which will be responsive to this group of patients in need? How do we prioritize pediatric emergency care among the many other funding needs, both medical and nonmedical? The answer lies with the initiative and advocacy of each of us as child advocates. Providing all the aforementioned elements of the EMS-C will save children's lives. These are lives which are usually responsive to therapy, uncomplicated by interlocking disease states, and filled with potential for future achievement. The challenge is ours.

Comparison of serum phenobarbital levels after single versus multiple attempts at intraosseous infusion

Serum drug levels from a single intraosseous attempt in nontraumatized bone have proven comparable to levels from IV drug infusions. However, in the clinical situation, inexperienced personnel may make multiple intraosseous attempts, which could allow significant extravasation from multiple intramedullary entrance sites. Serum drug levels arising from multiple intraosseous attempts in traumatized bone were compared with those arising from single intraosseous attempts in nontraumatized bone. We administered phenobarbital to 24 dogs randomly divided into single- (11) and multiple-attempt (13) groups. In the multiple-attempt group, we created three intramedullary insertion sites in a linear fashion and infused through only the central site. In the single-attempt group, only a single infusion site was created. Phenobarbital then was infused into the intramedullary space, and central venous phenobarbital samples were collected at one-, three-, six-, and ten-minute intervals. The single-attempt group attained significantly higher serum phenobarbital levels at each interval compared with the multiple-attempt group (P less than .0001). Therefore, to be an effective mode of therapy, it is critical to achieve single-attempt intraosseous needle placement for intraosseous infusion.

The bone marrow as a source of laboratory studies

The intraosseous route is an emergency alternative to the IV route for the administration of drugs and fluids. Another emergency function of intravascular access is obtaining blood samples for blood gases, laboratory studies, and blood cultures. One of the drawbacks to using the intraosseous route as an alternative to IV access has been the persistent need to establish IV access to obtain blood samples. We obtained bone marrow samples from ten healthy anesthetized dogs and analyzed the usefulness of the samples in providing meaningful laboratory studies when compared with simultaneous arterial and venous samples for blood electrolytes, blood chemistries, blood gases, and hemoglobin. There was no significant difference (P greater than .10) in blood electrolytes (sodium, potassium, chloride, and carbon dioxide) drawn from the intraosseous, arterial, and venous sites. The blood chemistries (blood urea nitrogen, creatinine, total protein, albumin, calcium, phosphorous, uric acid, total bilirubin, and SGOT) also were not significantly different (P greater than .10). Significant differences were obtained for glucose comparing intraosseous with arterial (P = .03), whereas intraosseous versus venous was only marginally significant (P = .06). Significant differences were also obtained for alkaline phosphatase when comparing intraosseous with arterial (P = .03), whereas comparison with venous was only marginally significant (P = .06): lactate dehydrogenase differences were marginally significant when comparing intraosseous with arterial (P = .09) and venous (P = .06) blood. Hemoglobin values were not significantly different when comparing results for the three sites (P greater than .25).(ABSTRACT TRUNCATED AT 250 WORDS)

Intravascular access in pediatric cardiac arrest

All cases of patients aged less than 48 months who presented in cardiac arrest to the Hennepin County Medical Center's emergency department (ED) during the years 1984 to 1986 were reviewed retrospectively. The ED record, initial and subsequent chest radiographs, hospital charts, and autopsy reports were analyzed. A total of 33 cases were reviewed. The average patient age was 5 months. The average time needed to establish intravascular access was 7.9 +/- 4.2 minutes. Success rates were 77% for central venous catheterization, 81% for surgical vein cutdown, 83% for intraosseous infusion, and 17% for percutaneous peripheral catheterization. Percutaneous peripheral catheterization, when successful, and bone marrow needle placement were the fastest methods of obtaining intravascular access. There were no major immediate complications, and delayed complications were minimal. Attempts at peripheral intravenous catheter placement should be brief, with rapid progression to intraosseous infusion if peripheral attempts are not successful.

Pediatric intraosseous infusions: impact on vascular access time

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

Intraosseous infusions by prehospital personnel in critically ill pediatric patients

A program to instruct ground and aeromedical prehospital emergency medical system providers in the intraosseous infusion technique was developed and implemented. Paramedics and flight nurses received training through lectures and performance of the procedure in several animal models. The records of attempts on 15 patients who subsequently received intraosseous infusions were then reviewed. An intraosseous infusion was successful in 12 of 15 attempts (80%), and all needles were placed in less than 30 seconds. Drugs administered included phenobarbitol, phenytoin, atropine, epinephrine, sodium bicarbonate, isoproterenol, and pancuronium. Observed complications were limited to minimal subcutaneous infiltration in three cases and slow infusion in another. No serious sequelae were noted, but most patients did not survive and the ability of this study to detect sequelae may be limited. These data suggest that intraosseous infusion is a safe and reliable technique in the prehospital setting. Research is needed to study this technique in more detail.

Treatment of hemorrhagic shock with intraosseous administration of crystalloid fluid in the rabbit model

Intravenous access can be very difficult to obtain in small hypotensive infants. We studied the ability of the intraosseous route to accept a large volume of resuscitation fluid administered to hypovolemic rabbits. Hypotension induced by withdrawing one-third of the blood volume of rabbits was treated by infusion of saline, IV or intraosseously. A control group was bled, but received no saline. All three groups experienced a drop in mean arterial blood pressure (MAP) to at least 50% of the prebleed baseline value. Also, all groups' heart rates dropped to between 90 and 95% of prebleed baseline values. A ten-minute infusion of a saline volume equal to three times the volume of blood removed reversed hypotension equally by the intraosseous and IV routes. After one-half of the fluid was administered, the MAP was 107 +/- 4% and 104 +/- 11% of baseline in the intraosseous and IV groups, respectively. In contrast, the control group had a MAP of 70 +/- 8% of baseline at the same time. At the end of the fluid bolus the intraosseous group had a MAP of 97 +/- 3% of baseline and the IV group a MAP of 99 +/- 8%. The control group continued to have a low MAP of 72 +/- 6% of baseline. Heart rates rose during fluid administration in both the intraosseous and IV groups, reaching 103 +/- 2% and 99 +/- 3%, respectively, at the end of fluid administration. The control group was 88 +/- 2% of baseline at the same time. The differences between the treatment groups and the control group were significant at the .05 level. The intraosseous route will allow sufficient flow of fluid to rapidly reverse hypotension secondary to hemorrhage in a small mammal (ie, the rabbit).

Endotracheal drug administration in the critical care setting

Administration of drugs through an endotracheal tube has been evaluated in a number of animal models. In addition, the technique has been utilized in humans as reported in several published cases. A review of endotracheal drug administration with emphasis on application to the critical care setting is presented.