September 13, 2012

Intraosseous Cannulation: Do We Need That in the Field?

Second Generation Bone Injection Gun (B.I.G)
There are various debates exist regarding pre hospital fluid resuscitation. Some studies shown that pre hospital fluid resuscitation is associated with increase in mortality rate. The examples are the study by Bickell et al (1994), Sampalis JS (1997) and Seamon MJ (2007).

The logic behind this is based on the premise of ‘permissive hypotensive.’ The idea is that, fluid resuscitation will increase the blood pressure and this will either distrupt the already formed fibrin plug or worsened the bleeding through the ‘extra’ pressure. Excessive fluid resuscitation are also associated with dilutional of the coagulation factors. Therefore, blood pressure should be maintained of at least SBP 90. This estimation of SBP can be made by palpating the radial artery. If it is palpable, therefore no more increment in blood pressure is needed. If absent, fluid challenge may be attempted through bolus of 250 cc saline. Apart from that, permissive hypotensive should be combined with 1) Controlled of external bleeding, 2) Promoting of the usage of pelvic binder and 3) Early definitive treatment ie; definitive surgery.

Attempting IV line may cause delay in patient’s transfer to the hospital. Jones SE (1989) found that average time to place IV line with single attempts is 2.8 minutes and failed attempts 6.3 minutes. According to Minville V (2006), the average time taken was 4.4 minutes with 99.7% success rate.

In considering to that, therefore the questions remain whether we really needs a vascular access?  According to Consensus Statement on prehospital trauma care (2000) made by a number of organization from UK, a few number of recommendation were made. 1) Transfer should not be delayed by attempt to obtain intravenous access. 2)  Cannulation should take place en route where possible. 3) Only two attempts at cannulation should be made. 4) Entrapped patients require cannulation at the scene. 5) Normal saline is recommended as a suitable fluid for administration to trauma patients. 6) Boluses of 250 ml fluid may be titrated against the presence or absence of a radial pulse (caveats; penetrating torso injury, head injury, infants).

For me, i think that this aspect need a further clarification and considered as a grey area in pre hospital care. I agree that most of the patient did not require IV fluids. However, this evidences are based on study conducted in urban area in which their ambulance response time is less than 10 minutes and easily access to level 1 trauma center. In a situation like east Malaysia in which it took longer time to reach hospital; some may take one to two hours. Therefore, i think that we should stay and play. Advanced airway, pelvic and spinal stabilization and vascular access should be available in order to optimize patient care prior to transfer. In prioritizing this, i think that vascular can be done last. Option includes 1) to perform it en route in the ambulance or 2) to consider intra osseous access in a patient who really required the fluid resuscitation.


EZ-IO Drill and Needle.

IO Device is  relatively new in our pre hospital care setting. Tracking back the history, IO procedure has been proposed by Drinker et al. in the 1920 and becoming more and more advanced in western country. It is simple and fast. The usage of battery support IO device can be performed by trained paramedic in less than 10 seconds (Marvin A Wayne 2009). Study by Frascone RJ (2007) who compare the usage of two IO devices FAST 1TM and EZ-IO found that EZ IO is more user friendly and can be placed faster. However, what i want to stress on is that, most of the patient who was put on this device had more initial IV attempts. Therefore, why wasting time for IV access if you can reduce the time and perform faster with IO device?

Studies shows that IO access fluid infusion are readily absorbed into the circulation including the infusion of medication. As this technology is expensive, it should not be done as a routine practice. However, i think that this technology should be considered to patient with difficult IV line access and proved to be beneficial from the intervention either for fluid or drug administration. The complication is rare and some of it including osteomyelitis, pain, extravasation of fluids, disruption of growth plate in children (related to insertion technique) and soft tissue infection. Therefore, our ambulance should at least equipped with this device for a real emergency need.

Once the access is available, again the debate arise. How much should we infused? What solution should we give? Monitoring and etc. Again, there are various debate regarding this section. To me, we should look at it based on individual case. For example, in trauma patient; i agree that we should allow for the permissive hypotension. Exception to this is that if the transfer time is prolong and patient become unstable through out the transfer, therefore we should consider traditional fluid resuscitation regime.

Otherwise fluid resuscitation should not be withheld in a non trauma case like hemodynamical instability due to shock, diabetic ketoacidosis, drug overdose, severe burn, severe dehydration,and overwhelming sepsis

Choices of fluids are depend. Either normal saline, other crystalloid and colloid should be instituted based on availability of local guidelines. The use of hypertonic saline is controversial and should not be advocated until the clear evidence or consensus is made.


Bryan A. Cotton et al, " Practice Management Guidelines For Prehospital Fluid Resuscitation In The Injured Patient", 2008 Eastern Association for the Surgery of Trauma

J Dretzke et al, "Clinical Effectiveness and Cost Effectiveness of Prehospital Intravenous Fluids in Trauma Patients" Health Technology Assessment 2004:vol 8 no 23

Marvin A Wayne, "Adult Intraosseous Vascular Access in Emergency Medicine", Touch Briefings 2009

1 comment:

  1. Very intresting post. Unfortunately I believe there is a gross mis representation of the Bickell article, the study limited fluids only in the penetrating trauma. It is still the standard of care to give fluids in the blunt trauma.
    Secondly, SBP does not calculate into end organ perfusion MAP should be evaluated. I absolutely agree that transfer should never be delayed due to lack of access, therefore just place and IO! How can one advocate for placing an advanced airway but not an IO, clearly there is a huge time difference in the application of each....

    Again I do believe that many of your ideas are interesting and thought provoking, however you should dive into the literature a little more.


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