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Hot Topics: CT Contrast and Intraosseous Lines: Friends or Enemies?
Hot Topics: CT Contrast and Intraosseous Lines: Friends or Enemies? j Valerie Aarne Grossman, MALS, RN, BSN Caring for the complex and variable patients who come to the computed tomography (CT) suite for scans is challenging given the rapid exchange and synthesis of information that brings together technology and patient assessment. There is a mix not only of the CT technology but also with the patient coming through the door. CT provides us with highly technical and multidimensional imaging ability as well as the diversity of the power injector and intravenous (IV) iodinated contrast . as well as the complexity of the patients who need CT scans . and the CT nurse supporting this modality is thrown into a highly challenging cutting-edge field of technology with potentially the sickest, most critical, and least stable patients in the department. The nurse often has only minutes to assess the patient for complete safety before injecting contrast: further complicate that when the patient arrives with an intraosseous line! Intraosseous (IO) lines were first described in the literature as far back as the 1800s when anatomists discovered the therapeutic utility of “marrow infusions” (Paxton, 2012). By the early 1900s, scientific
Valerie Aarne Grossman, MALS, RN, BSN is the Nurse Manager of the Medical Imaging Department at Highland Hospital (affiliate of University of Rochester), Rochester, NY. Disclaimer: This article reflects the knowledge and opinion of the author and not the Association for Radiologic and Imaging Nursing. Always follow the institution’s approved policies and procedures for contrast administration, as well as your State’s Nurse Practice Act. Corresponding author: Valerie Aarne Grossman, Medical Imaging Department at Highland Hospital (affiliate of University of Rochester), 11 Henry Circle, Rochester, NY 14624. E-mail: [email protected] J Radiol Nurs 2013;32:41-44 1546-0843/$36.00 Copyright Ó 2013 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2012.12.004
VOLUME 32 ISSUE 1
studies were under way to better understand the arterial and venous systems of the bone marrow, and in 1916, Harvard physicians described the bone marrow as a noncollapsible vein that could quickly transfer infused fluid from the bone marrow into the central circulation! (Drinker, Drinker, & Lund, 1922). It was not until the 1930s and 1940s that IO lines were widely used during World War II by military medics to treat wounded soldiers by infusing fluids and blood products (Dubick & Holcomb, 2000; Tocantins, O’Neill, & Price, 1941). With the invention of the plastic IV catheter in the 1950s, the use of IO lines dwindled (Tobias & Kinder-Ross, 2010). That is, until the 1980s when the value of IO cannulation was rediscovered and widely discussed through a passionate editorial written by an American pediatrician, Dr James Orlowski, who saved children’s lives in India during a cholera outbreak using IO lines (Orlowski, 1984). The American Heart Association adopted the use of IO lines as the standard of care in the Pediatric Advanced Life Support guidelines in the 1980s. In the 1990s, various companies began producing IO needles, and by 2006, the American Heart Association added the use of the IO lines to the Advanced Cardiac Life Support guidelines. Although IO lines may seem new to the imaging arena, they have been a near constant throughout the history of vascular infusion for over a century (Miller, 2006). What is common outside the CT suite does not immediately blend with what is necessary to safely perform a quality contrast scan for the patient. Those who use IO lines for patients are often taught that anything that can be infused through an IV can safely go through an IO line. When the patient comes to CT scan . does that mean that contrast for CT can safely be injected through an IO line? How will the timing of the scan be affected? Is the contrast safe for the bone marrow? Can a power injector be used and if so, at what rate or pressure? How does the nurse injecting verify the patency of the IO lines before injection? Will the resulting images produce visual information the radiologist needs to answer the diagnostic questions of the ordering physician?
www.radiologynursing.org
41
Grossman
JOURNAL OF RADIOLOGY NURSING
CT Contrast and Intraosseous Lines
Table 1. Available intraosseous products Manufacturer and IO product names Cook Critical Care Sur-Fast needle Sussmane-Raszynski needle Dieckmann needle Bloomington, Indiana Pyng Medical Corporation FAST 1 FAST X Vancouver, British Columbia TIAX Laboratory Reusable IO infusion device Lexington, MA
Vidacare Corporation EZ-IO Shavano Park, Texas
Waismed/Persys Medical Bone Injection Gun Herzelia, Israel
Sizes and accessories
Infusion rates
12-20 gauge needles Some with side holes Manual placement
N/A
Patients older than 12 years Sternal site only Spring-loaded applicator Removal tool (FAST 1)
Gravity drip: 30-80 mL/min Pressure bag: 125 mL/min Syringe: 150-250 mL/min
Current prototype for military use Sternal site only Reusable lightweight driver Single-use needles
Strictly insertion only: do not produce the IO needle
Sites: tibia, humerus, sternum 15-mm needle (3-39 kg) 25-mm needle (O39 kg) 45-mm needle (O39 kg) Battery powered rotary driver All needles are of 15 gauge
Humerus: Pressure bag: 828-9,000 mL/hr Tibia: Pressure bag: 336-3,300 mL/hr Must use: 45-mm needle for CT injections Never use: EZ-connect tubing with CT power injector
Adult: 15 gauge Pediatric: 19 gauge Spring-loaded applicator USA: tibial site only Israel: tibia, medial malleolus, and distal radius
Gravity drip: 5-10 mL/min (16 g) Pressure bag: 15-20 mL/min (16 g) Pressure bag: 30-40 mL/min (15 g) Syringe: 60-100 mL/min (15 g)
N/A Z not available; FAST Z First Access for Shock and Trauma. Pyng Medical Corporation; Vidacare Corporation; Waismed; TIAX Laboratories; Schwartz, Amir, Dichter, and Figenberg (2008); Spangler, 2012; Waisman & Waisman, 1997.
The new frontier of considering IO lines for IV contrast administration provides more questions than answers at this point; however, the imaging nurse needs to be well informed and ready for this evolution in practice. Understanding the different products on the market and that they are not all created equal is essential (Table 1). Before injecting an IO line, just as before injecting a peripheral or a central line, the nurse must understand the manufacturer’s recommendations, hospital policies, and those opines of any governing agencies. Depending on the manufacturer’s recommendations, the IO lines may or may not need to be aspirated to verify placement before CT injection; however, they do need to be easily flushed with 10 to 20 mL of saline before and after the contrast injection (Miller, 2012). Patient contraindications to having an IO line may include but are not limited to fracture of that limb, previous IO placement in that location, prosthetic joint near insertion site, sepsis, bone abnormalities (osteoporosis, osteogenesis imperfecta, etc), or the inability to keep 42
their limb immobile (Phillips et al., 2010). To clarify the old adage that “anything IV can go IO,” it is now more correctly stated that anything that can be infused through a peripheral IV can safely be infused through an IO line: drugs that require a central line cannot be infused through an IO line (Paxton, 2012). Exciting research is currently under way, for example, the “Observational Study of CT Dye Administration Through the Intraosseous Vascular Access Route” (United States National Institutes of Health, 2012) and new product development is occurring for the military with a convenient, “Re-usable IO Infusion Device” (Spangler, 2012). Until we have the results of the pending research or additional documented case studies, the imaging nurse who does use an IO line for CT contrast injections should consider the following: Check your State’s Nurse Practice Act for guidance as some states restrict the scope of practice involving IO lines
www.radiologynursing.org
MARCH 2013
CT Contrast and Intraosseous Lines
JOURNAL OF RADIOLOGY NURSING
The humerus is the location of choice for highpressure CT injection (Miller, Philbeck, Montez, & Puga, 2010) (Figure 1) Determine the size of the IO needle, length, flow rate, how it was placed (manual, mechanical, and traumatic), and how long the dwell has been to decrease extravasation risk The higher the flow rate through the IO the more painful it may be to the patient Mechanical placement (instead of manual) of the IO may decrease the risk of extravasation during power injection of contrast because of a more secure fit of the needle into the hole in the bone Assess how long the IO has been in place (should be no longer than 24-72 hr depending on the brand used) Using an EZ-IO brand needle for a CT contrast power infusion may not be “off label;” however, it may also not be listed by the US Food and Drug Administration as a specific indication for the device use either (Philbeck, 2012) If the IO is placed in the humerus, the arm should not be raised above the head during the CT scan or injection (Knuth, Paxton, & Myers, 2011) A 1 mL/s power injection is equivalent to 3,600 mL/hr; therefore, verify the flow rate of the IO needle your patient has placed (most IO lines can only handle 0.5 mL to 2.5 mL/s power injection, whereas some as high as 5 mL/s)
Grossman
Fluid viscosity will affect the injection rate through an IO line: be sure to use warmed contrast to decrease viscosity Always use a 45-mm IO needle for CT power injections (Miller, 2012) Extravasation of CT contrast is more likely to occur, if the IO needle is dislodged from its placement, if there were “multiple attempts” to place the IO line, if the needle used was too short for the patient size, or if the IO dwell is longer than recommended by the manufacturer Just as with central venous catheter or peripheral intravenous power injections, all tubings must be power rated and flushed with saline or contrast to prevent an air embolism. The CT environment is ever changing, and it is essential that its nursing support remains the cutting edge. Some outsiders may think that “any nurse can go do injections” yet to those who live within the CT suite, just the opposite is known as fact. As technology and patient presentations grow in complexity, the CT nurse must be hypervigilant in what current regulations outline, organizational policy dictates, how technologies fit together, and how other specialties may overlap with the CT modality. One miscalculation or misunderstanding, and an adverse patient outcome could occur. The “heat of the CT moment” should NEVER push the nurse to a rushed decision with inadequate information available or considered. References
Figure 1. Intraosseous line placed in the right proximal humerus. Image used with the permission of Dr Larry Miller, Vidacare. VOLUME 32 ISSUE 1
Drinker, C., Drinker, K., & Lund, C. (1922). The circulations in the mammalian bone marrow: With especial reference to the factors concerned in the movement of red blood-cells from the bone-marrow into the circulating blood as disclosed by perfusion of the tibia of the dog and by injections of the bone marrow in the rabbit and cat. American Journal of Physiology, 62(1), 1-92. Dubick, M.A., & Holcomb, J.B. (2000). A review of intraosseous vascular access: Current status and military application. Military Medicine, 165(7), 552-559. Knuth, T., Paxton, J., & Myers, D. (2011). Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals of Emergency Medicine, 57(4), 382-386. Miller, L. (2006). White paper. Intraosseous vascular access: An essential emergency medical skill. Retrieved from http://acls.mshpreps.com/EZ-IO/Supplement%20Materials/ Intraosseous%20Vascular%20Access.pdf. November 4, 2012. Miller, L., Philbeck, T., Montez, D., & Puga, T. (2010). A two-phase study of fluid administration measurement during intraosseous infusion. Annals of Emergency Medicine, 56(3), 151. Miller, L. (2012). E-mail communication, November 12, 2012. Orlowski, J. (1984). My kingdom for an intravenous line. American Journal of Diseases of Children, 138(9), 803.
www.radiologynursing.org
43
Grossman
JOURNAL OF RADIOLOGY NURSING
Paxton, J.H. (2012). Intraosseous vascular access: a review. Trauma. Retrieved from http://tra.sagepub.com/content/ early/2012/01/03/1460408611430175. June 2, 2012. Philbeck, T. (2012). E-mail communication, October 25, 2012. Phillips, L., Brown, L., Campbell, T., Miller, J., Proehl, J., & Youngberg, B., Consortium on Intraosseous Vascular Access in Healthcare Practice (2010). Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various health care settings: a consensus paper. Critical Care Nurse, 30(6), E1-E7. Pyng Medical Corporation. Retrieved from http://www.pyng. com/products/fast1/. November 11, 2012. Schwartz, D., Amir, L., Dichter, R., & Figenberg, Z. (2008). The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience. The Journal of Trauma: Injury, Infection, and Critical Care, 64(3), 650-655. Spangler, R. (2012). Director, Government Business Development TIAX LLC. E-mail communication.
44
CT Contrast and Intraosseous Lines
TIAX Laboratories. Retrieved from http://www.tiaxllc.com/ about-us/. November 11, 2012. Tobias, J., & Kinder-Ross, A. (2010). Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesthesia and Analgesia, 110(2), 391-401. Tocantins, L., O’Neill, J., & Price, A. (1941). Infusions of blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure. Annals of Surgery, 12, 1085-1092. United States National Institutes of Health. Clinical Trials. (2012). Retrieved from http://clinicaltrials.gov/ct2/show/ NCT01531686. November 11, 2012. Vidacare Corporation. Retrieved from http://www.vidacare.com/ EZ-IO/Products-Drivers.aspx. November 11, 2012. Waisman, M., & Waisman, D. (1997). Bone marrow infusion in adults. The Journal of Trauma-Injury, Infection, and Critical Care, 42(2), 288-293. Waismed. Retrieved from http://www.waismed.com/Products. html. November 11, 2012.
www.radiologynursing.org
MARCH 2013
Valerie Aarne Grossman, MALS, RN, BSN is the Nurse Manager of the Medical Imaging Department at Highland Hospital (affiliate of University of Rochester), Rochester, NY. Disclaimer: This article reflects the knowledge and opinion of the author and not the Association for Radiologic and Imaging Nursing. Always follow the institution’s approved policies and procedures for contrast administration, as well as your State’s Nurse Practice Act. Corresponding author: Valerie Aarne Grossman, Medical Imaging Department at Highland Hospital (affiliate of University of Rochester), 11 Henry Circle, Rochester, NY 14624. E-mail: [email protected] J Radiol Nurs 2013;32:41-44 1546-0843/$36.00 Copyright Ó 2013 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2012.12.004
VOLUME 32 ISSUE 1
studies were under way to better understand the arterial and venous systems of the bone marrow, and in 1916, Harvard physicians described the bone marrow as a noncollapsible vein that could quickly transfer infused fluid from the bone marrow into the central circulation! (Drinker, Drinker, & Lund, 1922). It was not until the 1930s and 1940s that IO lines were widely used during World War II by military medics to treat wounded soldiers by infusing fluids and blood products (Dubick & Holcomb, 2000; Tocantins, O’Neill, & Price, 1941). With the invention of the plastic IV catheter in the 1950s, the use of IO lines dwindled (Tobias & Kinder-Ross, 2010). That is, until the 1980s when the value of IO cannulation was rediscovered and widely discussed through a passionate editorial written by an American pediatrician, Dr James Orlowski, who saved children’s lives in India during a cholera outbreak using IO lines (Orlowski, 1984). The American Heart Association adopted the use of IO lines as the standard of care in the Pediatric Advanced Life Support guidelines in the 1980s. In the 1990s, various companies began producing IO needles, and by 2006, the American Heart Association added the use of the IO lines to the Advanced Cardiac Life Support guidelines. Although IO lines may seem new to the imaging arena, they have been a near constant throughout the history of vascular infusion for over a century (Miller, 2006). What is common outside the CT suite does not immediately blend with what is necessary to safely perform a quality contrast scan for the patient. Those who use IO lines for patients are often taught that anything that can be infused through an IV can safely go through an IO line. When the patient comes to CT scan . does that mean that contrast for CT can safely be injected through an IO line? How will the timing of the scan be affected? Is the contrast safe for the bone marrow? Can a power injector be used and if so, at what rate or pressure? How does the nurse injecting verify the patency of the IO lines before injection? Will the resulting images produce visual information the radiologist needs to answer the diagnostic questions of the ordering physician?
www.radiologynursing.org
41
Grossman
JOURNAL OF RADIOLOGY NURSING
CT Contrast and Intraosseous Lines
Table 1. Available intraosseous products Manufacturer and IO product names Cook Critical Care Sur-Fast needle Sussmane-Raszynski needle Dieckmann needle Bloomington, Indiana Pyng Medical Corporation FAST 1 FAST X Vancouver, British Columbia TIAX Laboratory Reusable IO infusion device Lexington, MA
Vidacare Corporation EZ-IO Shavano Park, Texas
Waismed/Persys Medical Bone Injection Gun Herzelia, Israel
Sizes and accessories
Infusion rates
12-20 gauge needles Some with side holes Manual placement
N/A
Patients older than 12 years Sternal site only Spring-loaded applicator Removal tool (FAST 1)
Gravity drip: 30-80 mL/min Pressure bag: 125 mL/min Syringe: 150-250 mL/min
Current prototype for military use Sternal site only Reusable lightweight driver Single-use needles
Strictly insertion only: do not produce the IO needle
Sites: tibia, humerus, sternum 15-mm needle (3-39 kg) 25-mm needle (O39 kg) 45-mm needle (O39 kg) Battery powered rotary driver All needles are of 15 gauge
Humerus: Pressure bag: 828-9,000 mL/hr Tibia: Pressure bag: 336-3,300 mL/hr Must use: 45-mm needle for CT injections Never use: EZ-connect tubing with CT power injector
Adult: 15 gauge Pediatric: 19 gauge Spring-loaded applicator USA: tibial site only Israel: tibia, medial malleolus, and distal radius
Gravity drip: 5-10 mL/min (16 g) Pressure bag: 15-20 mL/min (16 g) Pressure bag: 30-40 mL/min (15 g) Syringe: 60-100 mL/min (15 g)
N/A Z not available; FAST Z First Access for Shock and Trauma. Pyng Medical Corporation; Vidacare Corporation; Waismed; TIAX Laboratories; Schwartz, Amir, Dichter, and Figenberg (2008); Spangler, 2012; Waisman & Waisman, 1997.
The new frontier of considering IO lines for IV contrast administration provides more questions than answers at this point; however, the imaging nurse needs to be well informed and ready for this evolution in practice. Understanding the different products on the market and that they are not all created equal is essential (Table 1). Before injecting an IO line, just as before injecting a peripheral or a central line, the nurse must understand the manufacturer’s recommendations, hospital policies, and those opines of any governing agencies. Depending on the manufacturer’s recommendations, the IO lines may or may not need to be aspirated to verify placement before CT injection; however, they do need to be easily flushed with 10 to 20 mL of saline before and after the contrast injection (Miller, 2012). Patient contraindications to having an IO line may include but are not limited to fracture of that limb, previous IO placement in that location, prosthetic joint near insertion site, sepsis, bone abnormalities (osteoporosis, osteogenesis imperfecta, etc), or the inability to keep 42
their limb immobile (Phillips et al., 2010). To clarify the old adage that “anything IV can go IO,” it is now more correctly stated that anything that can be infused through a peripheral IV can safely be infused through an IO line: drugs that require a central line cannot be infused through an IO line (Paxton, 2012). Exciting research is currently under way, for example, the “Observational Study of CT Dye Administration Through the Intraosseous Vascular Access Route” (United States National Institutes of Health, 2012) and new product development is occurring for the military with a convenient, “Re-usable IO Infusion Device” (Spangler, 2012). Until we have the results of the pending research or additional documented case studies, the imaging nurse who does use an IO line for CT contrast injections should consider the following: Check your State’s Nurse Practice Act for guidance as some states restrict the scope of practice involving IO lines
www.radiologynursing.org
MARCH 2013
CT Contrast and Intraosseous Lines
JOURNAL OF RADIOLOGY NURSING
The humerus is the location of choice for highpressure CT injection (Miller, Philbeck, Montez, & Puga, 2010) (Figure 1) Determine the size of the IO needle, length, flow rate, how it was placed (manual, mechanical, and traumatic), and how long the dwell has been to decrease extravasation risk The higher the flow rate through the IO the more painful it may be to the patient Mechanical placement (instead of manual) of the IO may decrease the risk of extravasation during power injection of contrast because of a more secure fit of the needle into the hole in the bone Assess how long the IO has been in place (should be no longer than 24-72 hr depending on the brand used) Using an EZ-IO brand needle for a CT contrast power infusion may not be “off label;” however, it may also not be listed by the US Food and Drug Administration as a specific indication for the device use either (Philbeck, 2012) If the IO is placed in the humerus, the arm should not be raised above the head during the CT scan or injection (Knuth, Paxton, & Myers, 2011) A 1 mL/s power injection is equivalent to 3,600 mL/hr; therefore, verify the flow rate of the IO needle your patient has placed (most IO lines can only handle 0.5 mL to 2.5 mL/s power injection, whereas some as high as 5 mL/s)
Grossman
Fluid viscosity will affect the injection rate through an IO line: be sure to use warmed contrast to decrease viscosity Always use a 45-mm IO needle for CT power injections (Miller, 2012) Extravasation of CT contrast is more likely to occur, if the IO needle is dislodged from its placement, if there were “multiple attempts” to place the IO line, if the needle used was too short for the patient size, or if the IO dwell is longer than recommended by the manufacturer Just as with central venous catheter or peripheral intravenous power injections, all tubings must be power rated and flushed with saline or contrast to prevent an air embolism. The CT environment is ever changing, and it is essential that its nursing support remains the cutting edge. Some outsiders may think that “any nurse can go do injections” yet to those who live within the CT suite, just the opposite is known as fact. As technology and patient presentations grow in complexity, the CT nurse must be hypervigilant in what current regulations outline, organizational policy dictates, how technologies fit together, and how other specialties may overlap with the CT modality. One miscalculation or misunderstanding, and an adverse patient outcome could occur. The “heat of the CT moment” should NEVER push the nurse to a rushed decision with inadequate information available or considered. References
Figure 1. Intraosseous line placed in the right proximal humerus. Image used with the permission of Dr Larry Miller, Vidacare. VOLUME 32 ISSUE 1
Drinker, C., Drinker, K., & Lund, C. (1922). The circulations in the mammalian bone marrow: With especial reference to the factors concerned in the movement of red blood-cells from the bone-marrow into the circulating blood as disclosed by perfusion of the tibia of the dog and by injections of the bone marrow in the rabbit and cat. American Journal of Physiology, 62(1), 1-92. Dubick, M.A., & Holcomb, J.B. (2000). A review of intraosseous vascular access: Current status and military application. Military Medicine, 165(7), 552-559. Knuth, T., Paxton, J., & Myers, D. (2011). Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals of Emergency Medicine, 57(4), 382-386. Miller, L. (2006). White paper. Intraosseous vascular access: An essential emergency medical skill. Retrieved from http://acls.mshpreps.com/EZ-IO/Supplement%20Materials/ Intraosseous%20Vascular%20Access.pdf. November 4, 2012. Miller, L., Philbeck, T., Montez, D., & Puga, T. (2010). A two-phase study of fluid administration measurement during intraosseous infusion. Annals of Emergency Medicine, 56(3), 151. Miller, L. (2012). E-mail communication, November 12, 2012. Orlowski, J. (1984). My kingdom for an intravenous line. American Journal of Diseases of Children, 138(9), 803.
www.radiologynursing.org
43
Grossman
JOURNAL OF RADIOLOGY NURSING
Paxton, J.H. (2012). Intraosseous vascular access: a review. Trauma. Retrieved from http://tra.sagepub.com/content/ early/2012/01/03/1460408611430175. June 2, 2012. Philbeck, T. (2012). E-mail communication, October 25, 2012. Phillips, L., Brown, L., Campbell, T., Miller, J., Proehl, J., & Youngberg, B., Consortium on Intraosseous Vascular Access in Healthcare Practice (2010). Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various health care settings: a consensus paper. Critical Care Nurse, 30(6), E1-E7. Pyng Medical Corporation. Retrieved from http://www.pyng. com/products/fast1/. November 11, 2012. Schwartz, D., Amir, L., Dichter, R., & Figenberg, Z. (2008). The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience. The Journal of Trauma: Injury, Infection, and Critical Care, 64(3), 650-655. Spangler, R. (2012). Director, Government Business Development TIAX LLC. E-mail communication.
44
CT Contrast and Intraosseous Lines
TIAX Laboratories. Retrieved from http://www.tiaxllc.com/ about-us/. November 11, 2012. Tobias, J., & Kinder-Ross, A. (2010). Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesthesia and Analgesia, 110(2), 391-401. Tocantins, L., O’Neill, J., & Price, A. (1941). Infusions of blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure. Annals of Surgery, 12, 1085-1092. United States National Institutes of Health. Clinical Trials. (2012). Retrieved from http://clinicaltrials.gov/ct2/show/ NCT01531686. November 11, 2012. Vidacare Corporation. Retrieved from http://www.vidacare.com/ EZ-IO/Products-Drivers.aspx. November 11, 2012. Waisman, M., & Waisman, D. (1997). Bone marrow infusion in adults. The Journal of Trauma-Injury, Infection, and Critical Care, 42(2), 288-293. Waismed. Retrieved from http://www.waismed.com/Products. html. November 11, 2012.
www.radiologynursing.org
MARCH 2013