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
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http://www.emergencyunit.com
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