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Kay VC, Gehrz JA, Grady DW, Emerling AD, McGowan A, Reilly ER, Bebarta VS, Nassiri J, Vinals J, Schrader A, Zarow GJ, Auten JD. Application Times, Placement Accuracy, and User Ratings of Commercially Available Manual and Battery-Powered Intraosseous Catheters in a High Bone Density Cadaveric Swine Model. Mil Med 2023:usad407. [PMID: 37897689 DOI: 10.1093/milmed/usad407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/21/2023] [Accepted: 10/07/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating trauma patients with severe hemorrhage. However, little is known regarding the application times, placement accuracy, and end-user ratings of battery-powered and manual IO access devices. This study was specifically designed to fill these knowledge gaps on six FDA-approved IO access devices. MATERIALS AND METHODS Three experienced U.S. Navy Emergency Medicine residents each placed commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums in a randomized prospective experimental design. Devices included the battery-powered EZ-IO Rapid Infuser and the manual Jamshidi IO, PerSys NIO, SAM Manual IO, Tactical Advanced Lifesaving IO Needle (TALON), and PYNG First Access for Shock and Trauma 1 (30 trials per device, 10 per user, 210 total trials). Application times, placement accuracy in medullary (zone 1) and trabecular (zone 2) bone while avoiding cortical (zone 3) bone, and eight subjective user ratings were analyzed using ANOVA and nonparametric statistics at P < .05. RESULTS The EZ-IO demonstrated the fastest application times, high rates in avoiding zone 3, and the highest user ratings (P < .0001). The TALON conferred intermediate placement times, highest rates of avoiding zone 3, and second-highest user ratings. The SAM Manual IO and Jamshidi performed poorly, with mixed results for the PerSys NIO and PYNG First Access for Shock and Trauma 1. CONCLUSIONS The battery-powered EZ-IO performed best and remains the IO access device of choice. The present findings suggest that the TALON should be considered as a manual backup to the EZ-IO.
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Affiliation(s)
- Victoria C Kay
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Joseph A Gehrz
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Derek W Grady
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Alec D Emerling
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Andrew McGowan
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Erin R Reilly
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Joshua Nassiri
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jorge Vinals
- School of Physics and Astronomy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Andrew Schrader
- Division of Animal Resources, NMCSD San Diego, San Diego, CA 92134, USA
| | - Gregory J Zarow
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- The Emergency Statistician, Idyllwild, CA 92549, USA
| | - Jonathan D Auten
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Palazzolo A, Akers KG, Paxton JH. Complications of Intraosseous Catheterization in Adult Patients: A Review of the Literature. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2023. [DOI: 10.1007/s40138-023-00261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Drozd A, Wolska M, Szarpak L. Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices. Expert Rev Med Devices 2021; 18:855-864. [PMID: 34325586 DOI: 10.1080/17434440.2021.1962287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Obtaining successful vascular access is an essential component of the emergency and trauma setting. The modern practice of medicine advocates IO access for patients in a critical condition, especially when IV access is problematic or unobtainable. Various medical devices allowing for IO access have been coined and used in the management of critical patients.Areas covered: This study aims to review the literature regarding different intraosseous devices used to obtain vascular access (Bone Injection Gun (BIG), EZ-IO, NIO, Jamshidi, and First Access for Shock and Trauma (FAST-1) and discuss their clinical and experimental role in the emergency and trauma settings.Expert opinion: The development of medical technology contributes to an increasing number of intraosseous devices facilitating vascular access in challenging scenarios, including cardiopulmonary resuscitation, anaphylactic, or hypovolemic shock. Each of these devices provides an effective route for fluid resuscitation, drug delivery, laboratory evaluation, and shortening the timeframe for established vascular access, provided that the person obtaining the access is acquainted with the use of the device.
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Affiliation(s)
- Anna Drozd
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland
| | - Marta Wolska
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
| | - Lukasz Szarpak
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland.,Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland.,Outcomes Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, Bialystok, Poland
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Intraosseous access in the resuscitation of trauma patients: a literature review. Eur J Trauma Emerg Surg 2020; 47:47-55. [PMID: 32078703 DOI: 10.1007/s00068-020-01327-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/11/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Intraosseous (IO) catheters continue to be recommended in trauma resuscitation. Their utility has recently been debated due to concerns regarding inadequate flow rates during blood transfusion, and the potential for haemolysis. The objective of this review was to examine the evidence for intraosseous catheters in trauma resuscitation, and to highlight areas for future research. METHODS A PubMed and Embase search for articles published from January 1990 to August 2018 using the terms ("intra-osseous access" or "intraosseous access" or "IO access") AND trauma was performed. Original articles describing the use of an IO catheter in the resuscitation of one or more trauma patients were eligible. Animal, cadaveric studies and those involving healthy volunteers were excluded. RESULTS Nine studies, comprising of 1218 trauma patients and 1432 device insertions, were included. The insertion success rate was 95% and the incidence of complications 0.9%. Flow-rate data and evidence of haemolysis were poorly reported. CONCLUSION Intraosseous catheters have high insertion success rates and a low incidence of complications in trauma patients. Existing evidence suggests that IO transfusion is not associated with haemolysis, however, further studies in humans are needed. There is a paucity of flow rate data for blood transfusion via IO catheters in this population, although much anecdotal evidence advocating their use exists.
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Gendron B, Cronin A, Monti J, Brigg A. Military Medic Performance with Employment of a Commercial Intraosseous Infusion Device: A Randomized, Crossover Study. Mil Med 2019; 183:e216-e222. [PMID: 29420766 DOI: 10.1093/milmed/usx078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/03/2017] [Indexed: 11/12/2022] Open
Abstract
Background Obtaining intraosseous (IO) access remains an invaluable skill in the management and resuscitation of patients on the battlefield. The U.S. Army Combat Medic is currently trained to utilize a sternal IO device (FAST1® Intraosseous Infusion System); however, the Arrow® EZ-IO® Intraosseous Vascular Access System offers unique benefits including ease of use, reload ability, and placement location versatility. Studies have demonstrated high success rates in the operational settings using the EZ-IO® System; however, no prospective studies have been conducted to assess the performance of U.S. Army's conventional Combat Medics using the EZ-IO® System. We hypothesized that EZ-IO® System-naïve medics would have a statistically significant success rate advantage utilizing the proximal tibia approach versus proximal humerus approach. Methods A total of 77 U.S. Army Medics (Military Occupational Specialty [MOS] 68 W) volunteer participants were recruited to participate in this randomized, crossover study. Participants received a standardized audio-visual-enhanced lecture on EZ-IO® System use without hands-on training and then randomized into two study groups according to which anatomical approach they would attempt first. Results were analyzed to determine participants' first-attempt mean success rates, mean required time to properly place the needle into simulated humeral head and proximal tibial bone models, and mean survey results measuring the participant's subjective assessment of the two approaches to include, along with training and testing experience. The data of those not naïve to the employment of the EZ-IO® System were excluded. Results The primary outcome measurement of overall mean participant success rate with attempted insertions into proximal tibial and humeral head bone models was 88% and 86%, respectively, demonstrating no statistically significant difference by approach, with no significant learning or design confounding effects (p > 0.05). Secondary outcomes of mean procedural time and subjective comfort and skill benefit were reported. Successful procedure times between the two anatomical approaches demonstrated a statistically significant mean time advantage of 17.1 s (p < 0.05) in proximal tibia IO placement. Overall participant mean subjective comfort level utilizing the EZ-IO® System (0- to 10-point scale with a 0 being not comfortable and a 10 being very comfortable) was 8.2, with no statistically significant difference in comfort discovered when comparing the two approaches. Participants reported a mean subjective score (0-10 scale with a 0 providing no benefit and a 10 providing extreme benefit) of 9.3 when asked how beneficial their newly learned IO system skill was to their overall medical skillset. Conclusions The overall first-attempt success rates of U.S. Army Combat Medics employing the EZ-IO® System are similar to the success rates of FAST1® device employment and similar to the success of other provider cohorts using the EZ-IO® device. Coupled with perceived benefit of adding the EZ-IO® System to their combat medic skillset, these data warrant further study and consideration for the incorporation of commercial IO systems into U.S. Army Combat Medic initial, sustainment, and pre-combat training and standard issue equipment.
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Affiliation(s)
- Brett Gendron
- U.S. Army Baylor EMPA Residency Program, Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
| | - Aaron Cronin
- U.S. Army Baylor EMPA Residency Program, Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
| | - Jonathan Monti
- U.S. Army Baylor EMPA Residency Program, Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
| | - Andrew Brigg
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431
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Schauer SG, Naylor JF, Oliver JJ, Maddry JK, April MD. An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan. Am J Emerg Med 2018; 37:94-99. [PMID: 29753547 DOI: 10.1016/j.ajem.2018.04.068] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting. METHODS We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016. RESULTS During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study. CONCLUSIONS US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies.
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Affiliation(s)
- Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States; 59th Medical Wing, JBSA Lackland, TX, United States; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, United States.
| | - Jason F Naylor
- Madigan Army Medical Center, Joint Base Lewis McChord, Washington, United States
| | - Joshua J Oliver
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, United States
| | - Joseph K Maddry
- 59th Medical Wing, JBSA Lackland, TX, United States; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, United States
| | - Michael D April
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, United States
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Burgert JM, Martinez A, O'Sullivan M, Blouin D, Long A, Johnson AD. Sternal Route More Effective than Tibial Route for Intraosseous Amiodarone Administration in a Swine Model of Ventricular Fibrillation. PREHOSP EMERG CARE 2017; 22:266-275. [PMID: 28910187 DOI: 10.1080/10903127.2017.1358782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The pharmacokinetics of IO administered lipid soluble amiodarone during ventricular fibrillation (VF) with ongoing CPR are unknown. This study measured mean plasma concentration over 5 minutes, maximum plasma concentration (Cmax), and time to maximum concentration (Tmax) of amiodarone administered by the sternal IO (SIO), tibial IO (TIO), and IV routes in a swine model of VF with ongoing CPR. METHODS Twenty-one Yorkshire-cross swine were randomly assigned to three groups: SIO, TIO, and IV. Ventricular fibrillation was induced under general anesthesia. After 4 minutes in VF, 300 mg amiodarone was administered as indicated by group assignment. Serial blood specimens collected at 30, 60, 90, 120, 150, 180, 240, and 300 seconds were analyzed using high performance liquid chromatography with tandem mass spectrometry. RESULTS The mean plasma concentration of IV amiodarone over 5 minutes was significantly higher than the TIO group at 60 seconds (P = 0.02) and 90 seconds (P = 0.017) post-injection. No significant differences in Cmax between the groups were found (P <0.05). The Tmax of amiodarone was significantly shorter in the SIO (99 secs) and IV (86 secs) groups compared to the TIO group (215 secs); P = 0.002 and P = 0.002, respectively. CONCLUSIONS The SIO and IV routes of amiodarone administration were comparable. The TIO group took nearly three times longer to reach Tmax than the SIO and IV groups, likely indicating depot of lipid-soluble amiodarone in adipose-rich tibial yellow bone marrow. The SIO route was more effective than the TIO route for amiodarone delivery in a swine model of VF with ongoing CPR. Further investigations are necessary to determine if the kinetic differences found between the SIO and TIO routes in this study affect survival of VF in humans.
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Abstract
OBJECTIVE Current guidelines recommend the use of intraosseous access when IV access is not readily attainable. The pediatric literature reports an excellent safety profile, whereas only small prospective studies exist in the adult literature. We report a case of vasopressor extravasation and threatened limb perfusion related to intraosseous access use and our management of the complication. We further report our subsequent systematic review of intraosseous access in the adult population. DATA SOURCES Ovid Medline was searched from 1946 to January 2015. STUDY SELECTION Articles pertaining to intraosseous access in the adult population (age greater than or equal to 14 years) were selected. Search terms were "infusion, intraosseous" (all subfields included), and intraosseous access" as key words. DATA EXTRACTION One author conducted the initial literature review. All authors assessed the methodological quality of the studies and consensus was used to ensure studies met inclusion criteria. DATA SYNTHESIS The case of vasopressor extravasation was successfully treated with pharmacologic interventions, which reversed the effects of the extravasated vasopressors: intraosseous phentolamine, topical nitroglycerin ointment, and intraarterial verapamil and nitroglycerin. Our systematic review of the adult literature found 2,332 instances of intraosseous insertion. A total of 2,106 intraosseous insertion attempts were made into either the tibia or the humerus; 192 were unsuccessful, with an overall success rate of 91%. Five insertions were associated with serious complications. A total of 226 insertion attempts were made into the sternum; 54 were unsuccessful, with an overall success rate of 76%. CONCLUSIONS Intraosseous catheter insertion provides a means for rapid delivery of medications to the vascular compartment with a favorable safety profile. Our systematic literature review of adult intraosseous access demonstrates an excellent safety profile with serious complications occurring in 0.3% of attempts. We report an event of vasopressor extravasation that was potentially limb threatening. Therapy included local treatment and injection of intraarterial vasodilators. Intraosseous access complications should continue to be reported, so that the medical community will be better equipped to treat them as they arise.
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A Comparison of the Effects of Intraosseous and Intravenous 5% Albumin on Infusion Time and Hemodynamic Measures in a Swine Model of Hemorrhagic Shock. Prehosp Disaster Med 2016; 31:436-42. [PMID: 27210025 DOI: 10.1017/s1049023x16000509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Introduction Obtaining intravenous (IV) access in patients in hemorrhagic shock is often difficult and prolonged. Failed IV attempts delay life-saving treatment. Intraosseous (IO) access may often be obtained faster than IV access. Albumin (5%) is an option for prehospital volume expansion because of the absence of interference with coagulation and platelet function. Hypothesis/Problem There are limited data comparing the performance of IO and IV administered 5% albumin. The aims of this study were to compare the effects of tibial IO (TIO) and IV administration of 500 mL of 5% albumin on infusion time and hemodynamic measurements of heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), and stroke volume (SV) in a swine model of hemorrhagic shock. METHODS Sixteen male swine were divided into two groups: TIO and IV. All subjects were anesthetized and a Class III hemorrhage was achieved by exsanguination of 31% of estimated blood volume (EBV) from a femoral artery catheter. Following exsanguination, 500 mL of 5% albumin was administered under pressurized infusion (300 mmHg) by the TIO or IV route and infusion time was recorded. Hemodynamic measurements of HR, MAP, CO, and SV were collected before and after exsanguination and every 20 seconds for 180 seconds during 5% albumin infusion. RESULTS An independent t-test determined that IV 5% albumin infusion was significantly faster compared to IO (P=.01). Mean infusion time for TIO was seven minutes 35 seconds (SD=two minutes 44 seconds) compared to four minutes 32 seconds (SD=one minute 08 seconds) in the IV group. Multivariate Analysis of Variance was performed on hemodynamic data collected during the 5% albumin infusion. Analyses indicated there were no significant differences between the TIO and IV groups relative to MAP, CO, HR, or SV (P>.05). CONCLUSION While significantly longer to infuse 5% albumin by the TIO route, the longer TIO infusion time may be negated as IO devices can be placed more quickly compared to repeated IV attempts. The lack of significant difference between the TIO and IV routes relative to hemodynamic measures indicate the TIO route is a viable route for the infusion of 5% albumin in a swine model of Class III hemorrhage. Muir SL , Sheppard LB , Maika-Wilson A , Burgert JM , Garcia-Blanco J , Johnson AD , Coyner JL . A comparison of the effects of intraosseous and intravenous 5% albumin on infusion time and hemodynamic measures in a swine model of hemorrhagic shock. Prehosp Disaster Med. 2016;31(4):436-442.
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