I may have missed the initial thread, but does any one else have experience
of the use of these (Adult I/O) devices at other anatomical sites?
John Black
Oxford
-----Original Message-----
From: [log in to unmask] [mailto:[log in to unmask]]
Sent: 02 May 2003 16:46
To: [log in to unmask]
Subject: sternal I_O
I wonder if the sternal route is best here - the greater tuberosity of the
humerus may be more accessible from the side of the car, and ovoids the
risk of penetrating both sternal bone tables which may be already
fractured. When we used sternum for marrow sampling patients were rather
concerned too!!
>Thank you to everyone who contributed to this. Your comments of support
>were welcome.
>
>For those who don't know Fire Speak a dash(board) roll is where the roof
>is removed, the front doors are opened and the bottom of the A post (the
>one with the front door hinges on) is cut parallel with and adjacent to
>the door sill. A ram from the bottom of the B post (the one the front
>door lock fits into) to the A post at steering wheel height then
>literally rolls the dash forwards, lifting the steering wheel etc away
>from the patient.
>
>Lessons I have learned are that I could have used more Ketamine. I was
>cautious because of the long held distrust of i.m. opiates in shock. The
>key idea is the sternal i/o. I had the kit, and in the back of my mind
>knew of the work the Israeli's did on it. Marten kindly let me know this
>chap is doing fine so far, I just hope he will remember this e-mail
>sequence when I come in with a similar case and an i.v. in the
>breastbone! It will after all give the Paramedics and Fire Crew
>something to talk about. I hear them now....
>
>"There was this poor sod crippled in the crash, and the bloody doc just
>stabbed him through the heart he did!"
>
>Thanks again guys (and girls)
>
>Vic Calland
>
>-----Original Message-----
>From: [log in to unmask]
>[mailto:[log in to unmask]] On Behalf Of Rowley Cottingham
>Sent: 30 April 2003 23:26
>To: [log in to unmask]
>Subject: Re: Ideas please....
>
>
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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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Dr.Marten C. Howes MRCP(UK) FFAEM
Specialist Registrar
Accident and Emergency Medicine
Royal Preston Hospital
Preston
PR2 9HT
Lancashire, UK
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