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September 10, 2017

Top EMS Game Changers - #7: Intraosseous infusion

In the fall of 1994, I was a quarter of the way through medic school, trying to master invasive skills that marked the boundary between BLS and ALS. I was expecting to spend another character-building night in class hanging drips and pushing meds into a disembodied, vinyl arm with veins the size of macaroni.

Then I saw the packages of chicken drumsticks – nice and fresh, ready for baking, broiling or frying. Or for intraosseous insertion, it turned out.

The idea was to pierce the tibia – the drumstick handle – with a Jamshidi needle, by vigorously twisting the trocar back and forth at the insertion site. When you felt the bone give way, the tip of the needle was usually in the marrow. You’d confirm placement by infusing fluid without resistance or leaks.

The procedure seemed so much more advanced than plain-old IVs, I assumed IOs were on the leading edge of medical technology. I was wrong.

Intraosseous access: Veins versus bones

IO access was uncommon until World War II, when it was often used to bolus wounded, hypovolemic soldiers [1]. Research on children in 1941 had confirmed earlier findings that IO administration was nearly as effective as intravenous routes for fluid and medication [1, 2].

Despite its wartime success, the IO route didn’t gain popularity in civilian medicine until American pediatrician James Orlowski advocated IOs in his 1984 editorial, "My Kingdom for an IV Line." Orlowski had seen Indian caregivers establish peripheral IOs in children during a cholera epidemic, and recognized its benefit as an alternative to difficult IVs [1]. Six years later, Halverson, Bay, Perron, et al published an animal study of IOs predicting "safe and rapid vascular access via the sternal bone marrow space" and raising the possibility of IO lines for adults [3, 4].

Although many EMS systems added IOs for children under six in the 1990s, 1997 ACLS guidelines stated IOs should be inserted in peds only when IVs "cannot be established within minutes," and proposed the rule, "No IV in three tries, then go to intraosseous [5]." External jugular and endotracheal routes remained the recommended alternatives to peripheral IV lines in adults.

A millennial shift in Intraosseous infusion practice

IOs hadn’t gained much traction as of the American Heart Association’s 2000 ACLS update. In 2003, however, the AHA reported, "The interim conclusion appears to be very positive when adult IO devices are compared with traditional IV techniques [6]."

This was the beginning of the power tools era of IO, when drills started to replace manual administration sets. Vendors assured potential users that a trocar chewing into bone was no more painful than IV insertion. Some IO pundits backed up that claim by consenting to tibial punctures for public-relations purposes.

By 2005, the AHA was questioning the value of endotracheal drug dosing, and suggested instead that EMS providers establish IOs in all age groups "if IV access is unavailable [7]." Such liberal guidelines, plus accessibility to sternal and humeral IO sites, made the IV-versus-IO issue more a matter of judgment than protocol.

I hadn’t worked in a system where IOs were common, but after the 2010 ACLS update equated IOs to IVs, I started to hear paramedics from other agencies talk matter-of-factly about "drilling" their patients – often without even considering IVs [8]. I began to wonder whether IV skills would deteriorate, much as math and spelling skills did when replaced by high-tech alternatives.

I also felt conscious patients would be reluctant to allow any part of their anatomy to be drilled, regardless of their medics’ assurances that it wouldn’t hurt much. I haven’t been able to find any evidence to support those concerns.

The future of Intraosseous infusions

Despite assurances by the AHA and practitioners that IOs are safe and effective, I still see a few pending issues:

  • We know there are short-term risks such as compartment syndrome, infiltration, fracture and infection, but what are the long-term consequences of intraosseous excavation, if any [9]?
  • According to Gluckman in "Intraosseous Cannulation," IO needles should be removed within 3 to 4 hours [9]. To what extent are IOs instead of IVs in the field making extra work for hospital personnel and adding to patient discomfort?
  • Are all IO sites equally effective for drug and fluid administration? We don’t know [10].

I don’t mind lending my ample antecubital veins to students for IV practice, but being somewhat old-school and very protective of my bones, I don’t think I’ll be volunteering for IOs anytime soon.

References
1. Wayne M. Adult intraosseous access: an idea whose time has come. Israeli Journal of Emergency Medicine. 2006;6(2):41-45.

2. Foëx, B. Discovery of the intraosseous route for fluid administration. Journal of Accident & Emergency Medicine. 2000;17:136-137.

3. Halvorsen L, Bay BK, Perron PR, et al. Evaluation of intraosseous infusion device for the resuscitation of hypovolemic shock. Journal of Trauma and Acute Care Surgery. 1990;30(6):652-658.

4. McGonigal M. The trauma professional’s blog. www.regionstraumapro.com. Accessed 7/4/16.

5. American Heart Association. Advanced Cardiac Life Support. 1997.

6. American Heart Association. ACLS: Principles and Practice. 2003.

7. American Heart Association. American Heart Association Guidelines for CPR and ECC. 2005.

8. American Heart Association. Advanced Cardiovascular Life Support. 2011.

9. Gluckman W. Intraosseous cannulation. www.medscape.com. Accessed 7/5/16.

10. Burgert J, Gegel B, Loughren M, et al. Comparison of tibial intraosseous, sternal intraosseous, and intravenous routes of administration on pharmokinetics of epinephrine during cardiac arrest: a pilot study. American Association of Nurse Anesthetists Journal. 2012;80(4):S6-S10.

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