Not one to blow mine or my co-authors trumpets'  but there is an excellent
(?)
review article about this very subject
Trauma 1999;1:291-299 I Greaves, GA Evans, AA Boyle Intraosseous infusions
in the adult

Adrian Boyle

----- Original Message -----
From: "Black, John" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, May 02, 2003 5:07 PM
Subject: Adult I_O


> 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....
> >
> >
> >> This is a multi-part message in MIME format.
> >>
> >> ------=_NextPart_000_0010_01C30F51.90A1DB40
> >> Content-Type: text/plain;
> >>         charset="us-ascii"
> >> Content-Transfer-Encoding: 7bit
> >>
> >> 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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