Tag Archives: intraosseous

Humeral Intraosseous – Stay In & Stay Straight

This video shows the mechanism for dislodgement and deformation of humeral intraosseous needles and how to avoid this.
In summary, if you need to abduct the arm (eg. for thoracostomy), keep the thumbs down (ie. have the arm internally rotated at the shoulder). Otherwise the IO catheter may bend or fall out.

1. Pasley J, Miller CHT, DuBose JJ, Shackelford SA, Fang R, Boswell K, et al. Intraosseous infusion rates under high pressure. Journal of Trauma and Acute Care Surgery. 2015 Feb;78(2):295–9.
2. Paxton JH, Knuth TE, Klausner HA. Proximal Humerus Intraosseous Infusion: A Preferred Emergency Venous Access. The Journal of Trauma: Injury, Infection, and Critical Care. 2009 Sep;67(3):606–11.
3. Cho Y, You Y, Park JS, Min JH, Yoo I, Jeong W, et al. Comparison of right and left ventricular enhancement times using a microbubble contrast agent between proximal humeral intraosseous access and brachial intravenous access during cardiopulmonary resuscitation in adults. Resuscitation. 2018 Aug;129:90–3.
4. Knuth TE, Paxton JH, Myers D. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Ann Emerg Med. 2011 Apr;57(4):382–6.
5. Mitra B, Fitzgerald MC, Olaussen A, Thaveenthiran P, Bade-Boon J, Martin K, et al. Cruciform position for trauma resuscitation. Emerg Med Australas. 2017 Apr;29(2):252–3.
6. Reid C, Healy G, Burns B, Habig K. Potential complication of the cruciform trauma  position. Emergency Medicine Australasia. 2017 Apr 27;29:252.
7. Reid C, Fogg T, Healy G. Deformation of a humeral intraosseous catheter due to positioning for thoracostomy. Clin Exp Emerg Med. 2018 Sep;5(3):208–9.


Currently the RAGE Podcast site is recovering from a cold, so here are the show notes for the pre-SMACC mini RAGE episode released June 2015.
Here is the podcast
And here are the references:
SMACC Conference
It’s a knockout

GoodSAM App
Oxygen therapy
AVOID: Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction.
HOT or NOT trial: HyperOxic Therapy OR NormOxic Therapy after out-of-hospital cardiac arrest (HOT OR NOT): a randomised controlled feasibility trial.
Helicopter Emergency Medical Services
Survival benefit of a physician-staffed HEMS assistance for severely injured patients
Willingness to pay for lives saved by HEMS
Intraosseous access
Intraosseous infusion rates under high pressure: a cadaveric comparison of anatomic sites.
Intraosseous hypertonic saline: myonecrosis in swine
Intraosseous hypertonic saline: safe in swine
Discussion post about intraosseous hypertonic saline at Sydney HEMS
Handstands: a treatment for supraventricular tachycardia?
Impact of a modified Valsalva manoeuvre in the termination of paroxysmal supraventricular tachycardia
Handstands keep you awake
The next RAGE Podcast will air late August / early September

Caution with intraosseous adenosine

Two cases of failed cardioversion of SVT after tibial intraosseous administration of adenosine in infants are described in this month’s Pediatric Emergency Care. Both cases were subsequently cardioverted by intravenous adenosine. The maximum intraosseous dose given was 0.25 mg/kg. The successful IV doses were not higher than the IO doses.
It has been noted before that infants may require relatively higher doses of adenosine than children and that 0.2 mg/kg might even be considered a starting dose in infancy. I wonder if a bigger IO dose would have been effective, or whether a proximal humeral insertion site would make a difference. IO adenosine has been successfully used in infants and piglets.
This interesting case series provides a helpful caution in the management of paediatric SVT.

ABSTRACT: Supraventricular tachycardia (SVT) is a common tachyarrhythmia in the pediatric population that can necessitate immediate treatment. Adenosine has been well studied as a mainstay treatment, but the methods of adenosine administration have not been very well delineated. The intraosseous technique has presented itself as a possible method of administration. We describe 2 cases in which adenosine was administered through bone marrow infusion to convert SVT without success. The cases we describe show that intraosseous is not a reliable method of administering adenosine to stop SVT. Both patients presented with SVT refractory to vagal maneuvers and difficult intravenous placement. Intraosseous access was achieved, but administration of adenosine at increasing doses was unable to successfully convert the arrhythmia.

Intraosseous Infusion Is Unreliable for Adenosine Delivery in the Treatment of Supraventricular Tachycardia
Pediatr Emerg Care. 2012 Jan;28(1):47-8

FAST 1 success rates in the field

Three quarters of attempts to place the FAST 1 sternal intraosseous device were successful…

Introduction: Access to the vascular system of the critically ill or injured adult patient is essential for resuscitation. Whether due to trauma or disease, vascular collapse may delay or preclude even experienced medical providers from obtaining standard intravenous (IV) access. Access to the highly vascular intramedullary space of long bones provides a direct link to central circulation. The sternum is a thin bone easily identified by external landmarks that contains well-vascularized marrow. The intraosseous (IO) route rapidly and reliably delivers fluids, blood products, and medications. Resuscitation fluids administered by IV or IO achieve similar transit times to central circulation. The FAST-1 Intraosseous Infusion System is the first FDA-approved mechanical sternal IO device. The objectives of this study were to: (1) determine the success rate of FAST-1 sternal IO device deployment in the prehospital setting; (2) compare the time of successful sternal IO device placement to published data regarding time to IV access; and (3) describe immediate complications of sternal IO use.
Methods: All paramedics in the City of Portsmouth, Virginia were trained to correctly deploy the FAST-1 sternal IO device during a mandatory education session with the study investigators. The study subjects were critically ill or injured adult patients in cardiac arrest treated by paramedics during a one-year period. When a patient was identified as meeting study criteria, the paramedic initiated standard protocols; the FAST-1 sternal IO was substituted for the peripheral IV to establish vascular access. Time to deployment was measured and successful placement was defined as insertion of the needle, with subsequent aspiration and fluid flow without infiltration.
Results: Over the one-year period, paramedics attempted 41 FAST-1 insertions in the pre-hospital setting. Thirty (73%) of these were placed successfully. The mean time to successful placement was 67 seconds for 28 attempts; three of the 31 insertions did not have times recorded by the paramedic. Paramedics listed the problems with FAST-1 insertion, including: (1) difficulty with adhesive after device placement (3 events); (2) failure of needles to retract and operator had to pull the device out of the skin (2 events); and (3) slow flow (1 event). Emergency department physicians noted two events of minor bleeding around the site of device placement.
Conclusion: This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as a first-line device to obtain vascular access in the critically ill or injured patient. The FAST-1 sternal IO device can be a valuable tool in the paramedic arsenal for the treatment of the critically ill or injured patient. The device may be of particular interest to specialty disaster teams that deploy in austere environments.

Evaluation of success rate and access time for an adult sternal intraosseous device deployed in the prehospital setting
Prehosp Disaster Med 2011;26(2):127–129

EZ-IO in pre-hospital care

French pre-hospital physicians liked the EZ-IO intraosseous drill, using it for drugs (including rapid sequence intubation drugs) and fluids in the pre-hospital setting. There was a very high insertion success rate.
OBJECTIVE: Intraosseous access is a rapid and safe alternative when peripheral vascular access is difficult. Our aim was to assess the safety and efficacy of a semi-automatic intraosseous infusion device (EZ-IO) when using a management algorithm for difficult vascular access in an out-of-hospital setting.
METHODS: This was a one-year prospective, observational study by mobile intensive care units. After staff training in the use of the EZ-IO device and provision of a management algorithm for difficult vascular access, all vehicles were equipped with the device. We determined device success rate and ease of use, resuscitation fluid volume and drugs administered by the intraosseous route, and complications at insertion site.

RESULTS: A total of 4666 patients required vascular access. The EZ-IO device was used in 30 cardiac arrest patients (25 adults; 5 children) and 9 adults with spontaneous cardiac activity. The success rate for first insertion was 84%. Overall success rate (max. 2 attempts) was 97%. The device was used for fluid resuscitation in 16 patients (mean volume: 680ml), adrenaline administration in 24 patients, and rapid sequence induction in 2 patients. There was only one local complication (transient local inflammation).
CONCLUSIONS: On implementation of an algorithm for the management of difficult vascular access, the EZ-IO device proved safe and highly effective in both adult and paediatric patients in an out-of-hospital emergency setting. It is a suitable device for consideration as a first-line option for difficult vascular access in this setting.
Efficacy and safety of the EZ-IOTM intraosseous device: Out-of-hospital implementation of a management algorithm for difficult vascular access
Resuscitation. 2011 Jan;82(1):126-9

Less smelly than chicken drumsticks

Emergency and orthopaedic doctors Elizabeth and Anthony Bateman from Britain describe their method of making a bone simulator for intraosseous cannulation training:

  • Take up to one Crunchie bar per trainee (leave in wrapper!) – this simulates the cancellous bone that is cannulated.
  • Tightly plaster cast with four layers of polyester cast tape (12.5 cm width matches closely to Crunchie bar length), cutting lengths of the cast tape as needed prior to immersing in water – this simulates the hard cortical bone.
  • Foam padding, or two layers of wool band from the plaster room, can be added to simulate soft tissue.

A quick google reveals it can be a challenge getting Crunchie bars in the United States. Maybe there’s a suitable honeycomb-centred alternative. If not you can resort to ordering them from Amazon.
Intraosseus access simulation: the Crunchie solution
Emerg Med J. 2010 Dec;27(12):961

EZ-IO outperformed B.I.G

A small randomised trial of adult emergency department patients showed faster insertion and higher success rates with the EZ-IO compared with the Bone Injection Gun (B.I.G). This is in keeping with my own experience and that of several services I have worked for.


Bone Injection Gun

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study
Resuscitation. 2010 Aug;81(8):994-9

IO in OI

A case report describes three failed attempts to flush or secure an intraosseous needle placed using the EZ-IO drill during cardiac arrest of an adult patient subsequently noted to have osteogenesis imperfecta (OI) type III. While not listed as a contraindication to EZ-IO use by the manufacturer, one should consider that OI may result in procedural failure.
Intraosseous access in osteogenesis imperfecta (IO in OI)
Resuscitation. 2009 Dec;80(12):1442-3

Tibial vs humeral intraosseous approaches

An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO
Emergency physicians at Singapore General Hospital found flow rates to be similar when comparing the tibia with the humerus as sites for adult IO access. The EZ-IO had a very high insertion success rate. It took about 12 minutes to infuse a litre of saline, which drops to about 6 minutes if a pressure bag is used.
Am J Emerg Med. 2009 Jan;27(1):8-15