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> Perhaps some did not appreciate the fact we had nowhere for i.v. access,
> or was there somewhere else I could have gone (no reminders about an old
> line of argument with dog's corpora cavernosa please). What about
> intranasal with the skull fracture?
>
> Vic Calland
> Eventmed UK Ltd
> Training & Development beyond First-Aid
> Visit the website: http://www.eventmed.co.uk
>
Yes, no problem. However, ketamine needs to be given at a much higher dose im; around 10mg/kg -
yes, ten! The patient is then asleep for about 20 minutes. Did you consider a sternal IO? There
are several papers on this, with this Israeli one being one of the first:
J Trauma 1997 Feb;42(2):288-93
Bone marrow infusion in adults.
Waisman M, Waisman D.
Department of Orthopedic Surgery, Carmel Medical Center, Haifa, Israel.
OBJECTIVE: To asses the feasibility and success rate of vascular access through intraosseous
infusions in adults, in elective and emergency situations using a novel, automatic device, the bone
injection gun. DESIGN: A prospective, nonrandomized trial. MATERIALS AND METHODS: Two
groups of patients were prospectively selected over an 11-month period. Group 1: Adult patients with
recent closed long bone fractures, who underwent orthopedic surgery to upper and lower limbs and
needed regional anesthesia. Group 2: Adult patients who required emergency or semiemergency
vascular access, in whom intravenous central or peripheral cannulation could not be established
within a reasonable period of time. MAIN RESULTS: Fifty adult patients, aged 27 through 78 years,
underwent the procedure, which was universally successful. In group 1, n = 31 patients; in group 2 (n
= 19), 12 patients had multiple injuries, and seven underwent emergency resuscitation. In 76% of the
cases, the needle was inserted into the area of the tibial tuberosity; in the reminder of the cases, the
needle was inserted at the distal end of the radial bone and into the lateral or the medial malleolus.
The success rate for an adequate insertion was 100% in this group of patients. No complications from
the procedure were observed in this series. CONCLUSIONS: This study emphasizes the importance
and feasibility of the intraosseous route for infusion of fluids and medications in emergency
situations in adults. The use of an impact, high speed automatic needle insertion device provides a
higher success rate of vascular access via the intraosseal route in adult patients.
Resuscitation 2003 Feb;56(2):183-6
Successful intraosseous infusion in the critically ill patient does not require a medullary cavity.
McCarthy G, O'Donnell C, O'Brien M.
Department of Emergency Medicine, Cork University Hospital, Wilton, Cork, Ireland
OBJECTIVES: To demonstrate that successful intraosseous infusion in critically ill patients does not
require bone that contains a medullary cavity. DESIGN: Infusion of methyl green dye via standard
intraosseous needles into bones without medullary cavity-in this case calcaneus and radial styloid-in
cadaveric specimens. SETTING: University department of anatomy. PARTICIPANTS: Two adult
cadaveric specimens. MAIN OUTCOME MEASURES: Observation of methyl green dye in peripheral
veins of the limb in which the intraosseous infusion was performed. RESULTS: Methyl green dye was
observed in peripheral veins of the chosen limb in five out of eight intraosseous infusions into bones
without medullary cavity-calcaneus and radial styloid. CONCLUSIONS: Successful intraosseous
infusion does not always require injection into a bone with a medullary cavity. Practitioners
attempting intraosseous access on critically ill patients in the emergency department or prehospital
setting need not restrict themselves to such bones. Calcaneus and radial styloid are both an
acceptable alternative to traditional recommended sites.
Ann Emerg Med 1993 Jul;22(7):1119-24
Five-year experience in prehospital intraosseous infusions in children and adults.
Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS.
Medical College of Wisconsin, Milwaukee.
STUDY OBJECTIVE: To evaluate the ability of emergency medical technician-paramedic (EMT-P)
units to become and remain proficient in the performance of the intraosseous infusion procedure.
DESIGN AND SETTING: Descriptive nonrandomized trial open to all patients meeting protocol
criteria over a five-year period; prehospital urban and suburban area with a population of 951,000.
PARTICIPANTS: One hundred fifty-two consecutive patients (age range, newborn to 102 years) who
had intraosseous infusion line placement attempted by EMT-Ps. INTERVENTION: Jamshidi sternal
intraosseous infusion needle placed in the proximal tibia bone marrow in patients requiring
emergency vascular access for fluid and/or medication administration. RESULTS: EMT-Ps performed
165 attempts on 152 patients with a five-year success rate of 76% per patient and 70% per attempt.
Success rates per patient age group were 78%, 0 to 11 months; 85%, 1 to 2 years; 67%, 3 to 9 years;
and 50%, 10 years or older. Success rates were significantly higher in children 3 years old compared
with children and adults 3 or more years old (P = .04). Proficiency was maintained over the five-year
study period. Infiltration was the most common complication, occurring in 14 patients (12%). Errors in
landmark identification and needle bending were the most frequent identifiable causes for
unsuccessful attempts. Evidence of clinical response to fluid or medication infused was noted in 28
patients (24%). CONCLUSION: EMT-P units can successfully perform the intraosseous infusion line
procedure in patients of all ages. Proficiency is maintained over time despite its infrequent use by
individual EMT-Ps.
Best wishes,
Rowley Cottingham
[log in to unmask]
http://www.emergencyunit.com
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