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Intraosseous access and adults in the emergency department

Lowther A (2011) Intraosseous access and adults in the emergency department. Nursing Standard. 25, 48, 35-38. Date of acceptance: April 1 2011.

Summary
This article examines the use of the intraosseous route for obtaining vascular access in adults. It discusses indications for intraosseous access, the techniques and devices used, and contraindications.

Author
Ashleigh Lowther, Royal Air Force (RAF) nurse (emergency care), Deployable Aeromedical Response Teams, Tactical Medical Wing, RAF Lyneham, Chippenham; at time of writing was RAF nurse (emergency care), Bristol Royal Infirmary, Bristol. Email: ashbilly2000@yahoo.co.uk

Keywords
Cardiopulmonary resuscitation, emergency care, intraosseous access, vascular access devices These keywords are based on subject headings from the British Nursing Index. All articles are subject to external double-blind peer review and checked for plagiarism using automated software. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

in combination with several other interventions has been responsible for saving the lives of critically ill patients who would otherwise have died in modern military warfare in Afghanistan. The Resuscitation Council (UK) (2010) states that the administration of drugs via an endotracheal tube is no longer recommended and advise that, in the event of intravenous (IV) access being difficult or impossible, the intraosseous route should be considered for use in adults and children. The Resuscitation Council (UK) informs clinicians of the ability to collect bone marrow using an intraosseous device, which can also be used to measure venous blood gases as well as electrolyte and haemoglobin levels.

Intraosseous devices
Devices for intraosseous infusion are placed in the intraosseous space, which is the spongy, cancellous bone, more commonly known as the bone marrow and found in the long bones. DeBoer et al (2005) described the intraosseous space as a non-collapsible vein. The vessels of the intraosseous space connect directly to the central circulation (Infusion Nurses Society (INS) 2009). While there are many different ways in which to access the intraosseous space, this article examines manual, impact-driven and powered devices. Manual devices These devices are inserted manually using a small amount of force and usually a twisting motion until penetration of the cortex of the bone occurs (INS 2009). An example of such a device is the Dieckmann modification, which involves a stainless steel hub design by Cook Medical. Manual devices can be used on any long bone where access to the intraosseous space can be achieved. The trochar or stylet of the introducer is then removed and the intraosseous august 3 :: vol 25 no 48 :: 2011 35

THE INTRAOSSEOUS ROUTE as an option for vascular access was introduced following the discovery of circulation within mammalian bone in 1922 (Bohn 1999). During the 1930s and 1940s the intraosseous route was frequently used as a means of gaining vascular access, and a sternal puncture kit was commonplace in emergency medical kits used during the second world war (Cooper et al 2007). Advanced paediatric life support, pre-hospital paediatric life support and advanced trauma life support courses cover the techniques and advantages of the intraosseous route in the resuscitation of children (Lavis et al 2000). Hodgetts and Mahoney (2009) have shown that gaining rapid access via the intraosseous route NURSING STANDARD

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catheter is left in situ for the administration of fluid, blood products or drugs. Correct placement of the catheter in all intraosseous devices is ascertained by aspiration of bone marrow and/or by flushing 10ml of 0.9% sodium chloride with no increase in resistance (Vreede et al 2000, INS 2009). Impact-driven devices An example of an impact-driven device is the First Access for Shock and Trauma (FAST1) device (Pyng Medical 2011). This device is essentially a handheld introducer which when placed on the patients sternum at the correct angle and position, allows the clear plastic catheter with a stainless steel tip to penetrate the sternum no further than a predetermined depth. Powered devices The EZ-IO system (Vidacare 2011) is an example of a powered device (Figure 1). This battery-powered device consists of a disposable drill which has up to 1,000 uses and a sharp bevelled hollow needle with the central catheter inside (Cooper et al 2007). The device is usually inserted into the tibia, but can also be used in the humerus and femur.

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in critically ill patients in the emergency department. Although the sample size in this study was small, consisting of only ten patients, each had an EZ-IO and a CVC inserted. The results showed that gaining intraosseous access was a safe, reliable and rapid option for patients under resuscitation in the emergency department who have inaccessible peripheral veins. Leidel et al (2009) stressed that intraosseous access is not a replacement for CVCs; rather it is a bridging technique for initial lifesaving resuscitation. In addition, Leidel et al (2009) discussed the documented risks involved with both procedures. Venous thrombus, arterial puncture, pneumothorax, haemothorax and vascular site infections were associated with CVC insertion. Dislodgement of the device, fracture of the cannulated bone, extravasation, fat embolus and compartment syndrome were associated with intraosseous device insertion.

Intraosseous access sites and insertion

The most common sites for insertion of an intraosseous device although this can be dependent on the type of device used are the tibia, the lateral aspect of the humeral head (Figure 2), the sternum and less frequently the femur and iliac crest. According to Cooper et al (2007) insertion into the tibia should take place just below and medial to the tibial tuberosity (Figure 3). In studies carried out by Lamhaut et al (2010) and Leidel et al (2009) intraosseous device insertion was found to be fast and effective. Intraosseous access was gained within 40 seconds compared with over 60 seconds for IV access in the study by Lamhaut et al (2010). This study also tested the insertion of the device with practitioners wearing chemical, biological, radiological and nuclear protective clothing; nevertheless intraosseous insertion was again achieved much faster than IV access. Leidel et al (2009) showed mean insertion times of one to FIGURE 1 A powered intraosseous device (EZ-I0 system)
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Indications for intraosseous access

Intraosseous access should only be considered when IV access is difficult or impossible, potentially delaying treatment or resuscitation of the patient. Lamhaut et al (2010) stated that peripheral IV access is, and should remain, the first choice for most medical and trauma patients because accessing other routes can be time consuming. Sometimes delays in gaining IV access can be attributed to the injuries themselves, for example if there were extensive injuries to the limbs, or the patient is in shock, which causes the blood vessels to vasoconstrict. DeBoer et al (2005) discussed the effects that shock has on the body when it diverts blood to the major organs and subsequently away from most common peripheral IV sites. The intraosseous space with its network of blood vessels is not compromised during shock. Lavis et al (2000) described studies which showed that intraosseous access and infusion can be established in less than two minutes, with flow rates in the larger intraosseous needles shown to exceed that of a 16 gauge IV cannula placed in a subclavian vein. Macnab et al (2000) argued that intraosseous access should be an option in the resuscitation of critically ill or injured patients. If peripheral IV access is not possible then it is important to compare intraosseous access with alternatives such as central venous catheterisation. In a prospective observational study, Leidel et al (2009) compared the insertion of central venous catheters (CVCs) and intraosseous devices 36 august 3 :: vol 25 no 48 :: 2011

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three minutes for intraosseous insertion compared with five to 17 minutes for central venous catheterisation. Furthermore, Frascone et al (2007) and Leidel et al (2009) showed high success rates of insertion in trials (87% and 90% respectively). However, the sample sizes of these trials were different Frascone et al (2007) assessed insertion success in 178 insertions using two devices, whereas Leidel et al (2009) assessed success in ten insertions using one device. This suggests that the results of the study by Frascone et al (2007) are likely to be more generalisable.

Infusion using the intraosseous route

After insertion, the intraosseous catheter can then be used in the same way as an IV cannula for infusion of drugs, fluid and blood products. Guidance is available on which fluids and medications can be infused using an intraosseous device (Cooper et al 2007, Von Hoff et al 2008, Hartholt et al 2010). Hartholt et al (2010) stated that medications given through the intraosseous route enter the circulation almost as quickly as those given by IV infusion, even during cardiopulmonary resuscitation. A study by Von Hoff et al (2008) found no significant differences between IV and intraosseous infusion of morphine sulphate in almost all of the pharmokinetic parameters. Cooper et al (2007) published statistics of all fluids and drugs infused through an intraosseous device in a set period of time, ranging from cardiac drugs and blood products to anaesthetic agents, and did not identify any problems. It is recommended that an intraosseous device should not be left in situ for longer than 24 hours (INS 2009). It could therefore be argued that if some of the most pertinent lifesaving drugs and infusions have been given successfully, then the patients health should have improved enough to establish a more permanent means of IV access such as central venous catheterisation. It is important to note that once a more permanent means of IV access has been established, the intraosseous device should be removed.

Implementing the use of intraosseous devices in an emergency department would require training; however, with all of the devices discussed, training is quick and easy. Calkins et al (2000) conducted a trial of different intraosseous devices for use by US military personnel on special operations. They concluded that all of the devices trialled (manual and impact-driven) were easy to teach and to learn how to use. In trials where emergency medical personnel used the EZ-IO device for the first time, Levitan et al (2009) showed not only a high rate of success in accurate placement (289 out of 297 (97.3%) personnel), but also a willingness of participants (99%) to use the device in a cardiac arrest situation. One NHS trust in the UK that has implemented the use of the FIGURE 2 Intraosseous insertion site: humeral head

FIGURE 3 Intraosseous insertion site: tibial tuberosity

Limitations of intraosseous access

There are contraindications to intraosseous access in some patients (Box 1). Those aside, it is mainly cost, training issues or fear of complications that discourage use of the intraosseous route in adults. Intraosseous devices are more expensive than those used for IV access (see SP Services 2010). However, as mentioned previously, intraosseous access should only be considered in the resuscitation of critically ill or injured patients (Macnab et al 2000), and when attempts to obtain IV access have been unsuccessful (Resuscitation Council (UK) 2010). NURSING STANDARD BOX 1 Contraindications to intraosseous access 4Suspected fracture of the bone targeted for
insertion.

4Signs of infection around the insertion site. 4Previous surgery on the targeted bone. 4Excessive tissue over targeted site or lack
of landmarks.
(Infusion Nurses Society 2009, Leidel et al 2009)

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EZ-IO device compiled a competency-based document to allow clinicians to train in the skill using a step-by-step approach and to record such training (Ashford and St Peters Hospitals NHS Trust 2008). This indicates that the skill of inserting an intraosseous device can easily be taught to doctors and nurses working in the emergency department. While complications associated with intraosseous device insertion are rare, they can occur. Fenton et al (2009) highlighted one such problem when the metal tip from a FAST1 intraosseous device was left in a patients sternum after medical evacuation from Afghanistan. The authors cautioned clinicians about more frequently occurring risks such as cellulitis, osteomyelitis and extravasation. Tobias and Ross (2010) suggested that extravasation most commonly occurs when the intraosseous needle is dislodged from the intraosseous space, therefore care should be taken to protect device patency. In the most severe cases extravasation can lead to compartment syndrome, defined by Edwards (2004) as increased pressure in a closed fascial space which leads to capillary perfusion that is too low for tissue viability. This could be caused by

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continuing to infuse fluid through an intraosseous device that is no longer in the intraosseous space. Cooper et al (2007) acknowledged these complications, but stated that pain associated with the device remains the most common complication.

Conclusion
Intraosseous access should be reserved for the resuscitation of critically ill or injured patients. Quick insertion times mean that vascular access should be achieved easily allowing lifesaving medications and infusions to be administered, as well as providing an opportunity to analyse venous blood gases, haemoglobin and electrolyte levels. Associated complications such as extravasation and compartment syndrome might discourage some healthcare professionals from using the intraosseous route. However, this technique can save lives and should be considered in patients in whom obtaining intravenous access is difficult or impossible NS Acknowledgement The author would like to thank Rebecca Hoskins, nurse consultant, emergency department, Bristol Royal Infirmary and senior emergency care lecturer, University of the West of England for her help and support in the preparation of this article.

References
Ashford and St Peters Hospitals NHS Trust (2008) Intraosseous Needle Placement Using EZ-IO System. http://tiny.cc/Ashford748 (Last accessed: July 14 2011.) Bohn D (1999) Intraosseous vascular access: from the archives to the ABC. Critical Care Medicine. 27, 6, 1053-1054. Calkins MD, Fitzgerald G, Bentley TB, Burris D (2000) Intraosseous infusion devices: a comparison for potential use in special operations. Journal of Trauma. 48, 6, 1068-1074. Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A (2007) Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. Journal of the Royal Army Medical Corps. 153, 4, 314-316. DeBoer S, Seaver M, Morissette C (2005) Intraosseous Infusion: Not Just for Kids Anymore. http://tiny.cc/EMSWorld (Last accessed: July 14 2011.) Edwards S (2004) Acute compartment syndrome. Emergency Nurse. 12, 3, 32-38. Fenton P, Bali N, Sargeant I, Jeffrey SL (2009) A complication of the use of an intra-osseous needle. Journal of the Royal Army Medical Corps. 155, 2, 110-111. Frascone RJ, Jensen JP, Kaye K, Salzman JG (2007) Consecutive field trials using two different intraosseous devices. Prehospital Emergency Care. 11, 2, 164-171. Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB (2010) Intraosseous devices: a randomized controlled trial comparing three intraosseous devices. Prehospital Emergency Care. 14, 1, 6-13. Hodgetts TJ, Mahoney PF (2009) Military pre-hospital care: why is it different? Journal of the Royal Army Medical Corps. 155, 1, 4-8. Infusion Nurses Society (2009) INS Position Paper: The Role of the Registered Nurse in the Insertion of Intraosseous (IO) Access Devices. http://tiny.cc/INSposition (Last accessed: July 14 2011.) Lamhaut L, Dagron C, Apriotesei R et al (2010) Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation. 81, 1, 65-68. Lavis M, Vaghela A, Tozer C (2000) Adult intraosseous infusion in accident and emergency departments in the UK. Journal of Accident and Emergency Medicine. 17, 1, 29-32. Leidel BA, Kirchhoff C, Bogner V et al (2009) Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery. 3, 1, 24. Levitan RM, Bortle CD, Snyder TA, Nitsch DA, Pisaturo JT, Butler KH (2009) Use of a battery-operated needle driver for intraosseous access by novice users: skill acquisition with cadavers. Annals of Emergency Medicine. 54, 5, 692-694. Macnab A, Christenson J, Findlay J et al (2000) A new system for sternal intraosseous infusion in adults. Prehospital Emergency Care. 4, 2, 173-177. Pyng Medical (2011) FAST1 Intraosseous Infusion System. www.pyng.com/products/fast1 (Last accessed: July 14 2011.) Resuscitation Council (UK) (2010) Resuscitation Guidelines 2010. www.resus.org.uk/pages/ guide.htm (Last accessed: July 14 2011.) SP Services (2010) Intraosseous Products. http://tiny.cc/SPdevices (Last accessed: July 14 2011.) Tobias JD, Ross AK (2010) Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesthesia and Analgesia. 110, 2, 391-401. Vidacare (2011) What is the EZ-IO? www.vidacare.com/EZ-IO/Index. aspx (Last accessed: July 14 2011.) Von Hoff DD, Kuhn JG, Burris HA, Miller LJ (2008) Does intraosseous equal intravenous? A pharmokinetic study. American Journal of Emergency Medicine. 26, 1, 31-38. Vreede E, Bulatovic A, Rosseel P, Lassalle X (2000) Intraosseous infusion. Update in Anaesthesia. 12, 38-40.

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