Intraosseous Access

So, as we all know, there are loads of presentations that we see in Emergency Medicine that require us to gain rapid access to the circulation. Either to administer medicines around the body or to get fluids into the circulation.  Now there’s a number of different ways we can get them into the circulatory system for them then to get to their sites of action, each of which comes with its pros and cons. There’s buccal, inhaled, intramuscular, sublingual, intranasal etc etc….  But, in the vast majority of cases we gain this access to the vasculature through intravenous access and a peripheral cannula. That means that iv access is a very common procedure in emergency care. The great news is that the equipment is cheap, there are multiple sites for insertion and it’s often feasible regardless of the patients age or presenting complaint. Compared to all the other options for drug administration, iv access and administration of drugs via the IV route, results in 100% bioavailability of all medicines because it avoids the first pass metabolism in the liver, and distribution around the body is rapid because it bypasses the need for absorption into the vasculature. So that’s all good, so why are we doing an episode on intraosseous access then? Well, iv access and we as clinicians, are not infallible. And as we’re all too aware, gaining IV access can be challenging. There are other patient factors to like iv drug use, the morbidly obese and paediatric patients when everything is just smaller and more unfamiliar. So all of these factors increase the technical difficulty of iv cannulation. If we add to that some of the environmental issues we might find in the prehospital setting – so poor lighting or difficult patient access, it’s not a huge leap to realise that it would be great to have an alternative vascular access option available to a broad range of emergency care providers. And this is where IO access comes in.  So what will we be covering in this episode; -A recap on the anatomy of bones -Indications for IO access -The evidence on IO access and administration -Insertion site -Needle selection -Contraindications -Case examples Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Enjoy!

Simon, Rob & James

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Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review. Asger Granfeldt. Resuscitation. 2020

Intraosseous access in the prehospital setting-ideal first-line option or best bailout? Richard M Lyon. Resuscitation. 2013

Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial. Jerry P Nolan. Intensive Care Med. 2020

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Mohamud R Daya. Circulation. 2020

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Mohamud R Daya. Circulation. 2020

Maximising intraosseous flow rates: an in-vitro study. Rob Fenwick. Journal of Paramedic Practice. 2019

Intraosseous infusion rates under high pressure: a cadaveric comparison of anatomic sites. Jason Pasley. J Trauma Acute Care Surg. 2015

Pre-hospital intraosseous use in children: Indications and success rate. Amy Ting. Emerg Med Australas. 2022

Intraosseous versus intravenous access while wearing personal protective equipment: a meta-analysis in the era of COVID-19. Anna Drozd. Kardiol Pol. 2021

A comparison of proximal tibia, distal femur, and proximal humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model. Julio Lairet. Prehosp Emerg Care. 2013

An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. Marcus Eng Hock Ong. Am J Emerg Med. 2009

Intraosseous access in the resuscitation of trauma patients: a literature review. Joseph Antony Tyler. Eur J Trauma Emerg Surg. 2021

Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Philippa Lewis. EMJ. 2015

Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Mark A Horton. Pediatr Emerg Care. 2008

EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience. Justin J W Garabon. Prehosp Emerg Care. 2022

Anatomical investigations on intraosseous access in stillborns – Comparison of different devices and techniques

Zeynep Fuchs. Resuscitation. 2018

Arrow® EZ-IO® Intraosseous Vascular Access System. 2017 The Science and Fundamentals

of Intraosseous Vascular Access

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