Intraosseous infusions by prehospital personnel in critically III pediatric patients

ORIGINAL CONTRIBUTION infusion, intraosseous, pediatric

Intraosseous Infusions by Prehospital Personnel in Critically III Pediatric Patients A program tO instruct ground and aeromedical prehospital emergency medical system providers in the intraosseous infusion technique was developed and implemented. Paramedics and flight nurses received training through lectures and performance of the procedure in several animal models. The records of attempts on 15 patients who subsequently received intraosseous infusions were then reviewed. An intraosseous infusion was successful in 12 of 15 attempts (80%), and all needles were placed in less than 30 seconds. Drugs administered included phenobarbitol, phenytoin, atropine, epinephrine, sodium bicarbonate, isoproterenol, and pancuronium. Observed complications were limited to minimal subcutaneous infiltration in three cases and slow infusion in another. No serious sequelae were noted, but most patients did not survive and the ability of this study to detect sequelae may be limited. These data suggest that intraosseous infusion is a safe and reliable technique in the prehospital setting. Research is needed to study this technique in more detail. [Smith RJ, Keseg DE Manley LK, Standeford T: Intraosseous infusions by prehospital personnel in critically ill pediatric patients. Ann Emerg Med May 1988;17:491-495.] INTRODUCTION The prehospital delivery of advanced pediatric life support (APLS) for victims of cardiopulmonary arrest and major trauma is a critical phase in the emergency medical services [EMS) system. In the pediatric population, outcome from cardiac arrest is universally poor, whether it occurred in the hospital a-s or in the field.3,4, 6 Vascular access is an early goal in the application of APLS, z but establishing an IV line in children during an arrest or following multiple trauma is extremely difficult and time consuming. Tsai et al,8 in a review of prehospital care of pediatric emergencies, found that for children from 2 to 12 months old and 1 to 6 years old, the IV success rate was 29% and 66%, respectively. Furthermore, in the pediatric cardiac arrest victims of all ages an IV line was established in approximately 50%, but no IV line was placed successfully in patients less than 6 years of age. In a retrospective survey of pediatric ED arrests, 9 6% of patients failed to have an IV line placed and 24% required m o r e than ten minutes for IV access, with children less than 2 years old requiring significantly prolonged times. Those patients who were resuscitated successfully had IV access accomplished significantly sooner. These figures suggest the need for faster IV access. A heretofore under-used option in the prehospital arena is the use of intraosseous (IO) infusions. While m u c h has been written in the recent literature concerning this procedure, few have advocated its use in the field. We developed a training program to instruct both ground and aeromedical personnel in the IO technique. We then examined the success rate and complications of IO infusions in critically ill pediatric patients.

Ralph J Smith, MD* David P Keseg, MDt Linda K Manley, RN:t Thomas Standeford, MD~r Columbus, Ohio From the Columbus Children's Hospital, The Ohio State University;* the Columbus Fire Department;t and the Life Flight/ Trauma Service, Grant Hospital,* Columbus, Ohio. Received for publication December 29, 1987. Accepted for publication February 12, 1988. Address for reprints: Ralph J Smith, MD, Emergency Services, Columbus Children's Hospital, 700 Children's Drive, Columbus, Ohio 43205.

MATERIALS A N D M E T H O D S The Columbus metropolitan area is serviced by both ground ambulance and rotary transports. There are ten squads with a paramedic and an emergency medical technician (EMT), four medic vehicles with three paramedics, and four rescue vehicles that also have three paramedics. The paramedics function in an autonomous manner without the immediate presence of a 17:5 May 1988

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INTRAOSSEOUS INFUSIONS Smith et al

physician or base station but instead rely on carefully constructed protocols. On any critically ill pediatric patient, both a squad and a medic are dispatched. Both EMTs and paramedics were instructed in the technique as the squad may be the first to arrive at the scene. The aeromedical (rotary) wing component of the pediatric phase encompasses a referral area of 35 counties. The flight crew consists of a flight nurse and a flight medic who work under the direction of a medical control physician and standing protocols. The Life Flight/Trauma Service receives requests for transfer from referral hospitals and also responds to scene accidents. The prehospital personnel received their training as part of regularly scheduled continuing medical education courses. These sessions were three to four hours each and consisted of a one- to two-hour lecture that explained the basics of IO infusion, followed by a one- to two-hour "handson" clinical workshop. The lecture reviewed the history, indications, contraindications, drug/ fluid absorption, anatomical landmarks, and complications of IO infusions. Potential indications included cardiac arrest, hypovolemic shock, near-sudden infant death syndrome, multiple trauma, status epilepticus, and near drownings. Students were instructed to try to establish a peripheral IV before using an IO. The preferential site for insertion was the anterior medial surface of the tibia, 2 cm below the tibial tuberosity. Optional sites included the distal anterior femur, the medial melleolus, and the iliac crest. After preparing the area with Betadine% the needle was to be inserted through the skin and fascia and advanced through the cortex of bone with a boring motion. Three factors confirmed proper placement: the sudden lack of resistance, needle standing upright without support, and free flow of infusion. The needle then was securely taped into position. After establ i s h m e n t of an intraosseous line, fluids and/or drugs could be delivered at room air or under pressure. The clinical sessions began with familiarization with the Illinois sternal/ iliac bone marrow aspiration needle (15 g) or the Jamshidi modified Illinois aspiration needle (16 g) (American Pharmaseal ®, Glendale, California). 98/492

Each ground paramedic had a chance to insert one of these needles into a m e d i u m - s i z e d t u r k e y leg or large chicken thigh. Flight personnel performed infusions on anesthetized or deceased dogs less than 20 weeks old, using the proximal tibia or distal femur. After establishing intraosseous access, the needles were infused with approximately 10 mL of dyed saline. In the majority of cases the needles were inserted successfully and the IO infusions ran without difficulty. The Illinois bone marrow needles were then placed in all squad, medic, and rescue vehicles. After each IO attempt, the prehospital EMS members were to fill out a checklist of the following variables: estimated length of time to start IO line, number of initial IV attempts before performing an IO infusion, number of IO infusion attempts, degree of difficulty, indications for the IO infusion, medications/ fluids infused, initial vital signs, site versus hospital insertion, success/ failure, and complications. All ED and hospital records were reviewed for each patient receiving an IO infusion. The study period extended from December 1986 to December 1987 for the helicopter service and from June 1987 to December 1987 for ground transports.

RESULTS During the study period 15 IO infusions were attempted in 13 children (Table). The average age of the patients was 2.1 + 1.5 years. The proximal tibia was used in all cases. Ground paramedics attempted placement i n 33.3% of patients (cases 1 to 5) and air, medical personnel placed 66..6% (cases 6 to 13). The procedure was performed at the scene in ten of 15 cases (66.6%) and one in flight. The instances in which a bone marrow infusion was placed at a hospital were all performed by flight nurses and paramedics. Patients managed by ground ambulance crews had two or fewer IV attempts per patient, while the majority transported by aeromedical personnel had four or more attempts reflecting continued efforts at vascular access by the referring physicians prior to their arrival. There was successful placement in 12 of 15 cases (80%), with one patient receiving two infusions. The three instances in which there was failure to place an IO infusion were related to failure to adhere to landmarks (case 3) Annals of Emergency Medicine

and a bent needle (case 8). All successful cases required only one IO attempt to establish vascular access. There were multiple indications for the use of the IO infusion, including multiple trauma, 4 airway obstruction, z and one each for septic shock, near drowning, ingestion, sudden infant death syndrome, electrocution, smoke inhalation, and an unknown. The various drugs given intraosseously included atropine, sodium bicarbonate, epinephrine, isoproterenol, phen o b a r b i t a l , p h e n y t o i n , and pancuronium. Only crystalloid solutions were used in fluid resuscitation. The IO lines were used less than one hour in all cases or until patients were pronounced dead. Complications were limited to leakage of fluid at the site in three patients, one slow infusion, and one accidental dislodgement. No serious immediate complications related to the use of IO infusion were found. Nine patients presented in asystole and there were only two patients who survived to discharge; neither had residual neurological deficits. Paramedics graded the level of difficulty of insertion on a scale of 1 through 10; 91% (ten of I1) evaluated the difficulty as 1 (the easiest), with the remaining response given a level 2 degree of difficulty. All IO aeedles were estimated to be placed in less than 30 seconds. DISCUSSION The IO technique for fluid and drug delivery has been reviewed extensively.lO-16 These reports have concentrated on descriptive techniques and/ or isolated case reports Of various substances safely infused into h u m a n bone marrow. The pediatric use has included sodium bicarbonate, l~ phenytoin,17 catecholamines,18 succinylcholine, and diazepam, 19 and_in adults dexameth~sone, atropine, lidocaine, heparin, and diazoxide, zo More recently a number of investigators have studied the physiologic responses of fluids and drugs in animal models. Several reports have shown that the bone marrow reflects metabolic changes in the central circulation not 0nly in homeostatic states, zl but also during respiratory arrest, zz Shoot et a123 demonstrated that high flow rates up to 41 mL/min were obtainable in a n o r m o t e n s i v e bovine model using a 13-g tibial IO needle and pressurized infusion. In a hypo17:5 May 1988

TABLE. Summary of patients receiving I 0 infusion

Case Age 1 8 yr

Sex Indications Rhythm M Arrest, smoke Asystole inhalation

2

3 mo

M Arrest, aspiration

3

2 yr

4

4 mo

M Arrest, Asystole electrocution F Arrest, SIDSt Asystole

5

2 yr

F

6

2 yr

F

7

15 mo

8

5 yr

M

9

2 yr

M

10 18 mo

11

15 mo

12

4 mo

13

2 yr

Hypovolemic shock, pit bull mauling

Asystole

Asystole

Arrest, airway Asystole obstruction M MT, MVA Asystole

MT, crush injury Malathion OD, seizures, respiratory arrest MT, MVA

Agonal

Medications Epinephrine, LR infusion

IV IO Attempts Attempts Complications Site 1 1 None Scene

Epinephrine

2

1

None

Scene

None

1

1

Failed

Scene

Outcome Died after 3 days Died after 2 days DOA

Epinephrine, atropine, isuprel drip, LR infusion LR 300 mL, LR infusion, 100 to 200 mWhr Bicarbonate, LR 25 mL Epinephrine, bicarbonate, LR 100 mL None

2

1

None

Scene

DOA

2

1

None

Scene

DOA

2

2*

DOA

2

1

Slight leakage Scene at site Pulled out Scene accidentally

5

2

Bent needle

Scene

DOA

5

1

None

Scene, in flight

Normal

5 •

1

Slight leakage Hospital Died in at site ED

6

1

Slight leakage Hospital Died in at site ED

4

1

None

5

1

Slow infusion medications given successfully

Sinus Atropine, bradycardia pancuronium, D5, 2NS 260 mL M Asystole Bicarbonate, epinephrine, LR 100 mL M Arrest, TOGV BradycarBicarbonate, dia, EMD isuprel, LR 50 mL M Arrest, septic Asystole, Epinephrine, shock EMD bicarbonate F Near Sinus Phenobarbidrowning, tachycardia tal, phenytoin seizure

DOA

Hospital Died in ED Hospital Normal

*Both successful. tMT, multiple trauma; MVA, motor vehicle accident; OD, overdose; SIDS, sudden infant death syndrome; EMD, electromechanical disassociation; LR, lactated Ringer's; T©GV, transposition of the great vessels.

volemic "pediatric" model 24 comparing 20- and 13-g needles, significant restrictions to fluid delivery were found, apparently due to flow through the bone marrow rather than needle size. They concluded that the bone marrow may not be adequate for fluid resuscitation. However, this study design was limited by small sample size, reutilization of the same sites, and 17:5 May 1988

failure to mention if the subject animals were rendered hypotensive between experiments. Schoffstall et al 2s redemonstrated that needle size is not the critical factor in volume infusion but that the larger marrow cavity will improve infusion rates. Their rates supported the use of IO for volume resuscitation in infants and children. Other hypotenAnnals of Emergency Medicine

sive models have shown comparable correction with crystalloid when comparing central venous line and IO 26 and peripheral, central venous line and IO infusions. 27 A number of studies have demonstrated the adequacy of the marrow for absorption of various drugs. Earlier work in a canine model supported the use of IO sodium bicarbonate as an ef493/99

INTRAOSSEOUS INFUSIONS Smith et al

f e c t i v e m e t h o d of a d m i n i s t r a t i o n , z8 T h e safety of i n j e c t i n g t h i s h y p e r t o n i c s o l u t i o n h a s b e e n e s t a b l i s h e d , go In a c o m p a r i s o n of IO, c e n t r a l v e n o u s lines, a n d p e r i p h e r a l r o u t e s of s o d i u m bicarbonate in an animal arrest model, t h e c e n t r a l l y a n d i n t r a o s s e o u s l y delivered buffer m a i n t a i n e d a n e l e v a t e d p H l o n g e r t h a n p e r i p h e r a l delivery, sugg e s t i n g a g r e a t e r c o n c e n t r a t i o n of sodium bicarbonate reaching the central c i r c u l a t i o n . 29 Intraosseous epinephrine has been s h o w n t o e f f e c t i v e l y r a i s e m e a n arterial p r e s s u r e i n n o r m o t e n s i v e calves w i t h i n i t i a l effect a t 17 s e c o n d s a n d p e a k e f f e c t a t 45 s e c o n d s . 2g A d d i tionally, a t r o p i n e t h r o u g h t h e IO r o u t e takes a shorter time to reach peak p l a s m a c o n c e n t r a t i o n a n d yields h i g h er m e a n p l a s m a levels w h e n c o m p a r e d w i t h e n d o t r a c h e a l delivery. 31 F u r t h e r s t u d i e s of d r u g a b s o r p t i o n h a v e s h o w n t h e IO i n f u s i o n of p h e n o b a r b i t a l to b e s u p e r i o r to IV a d m i n istration in achieving and maintaining s e r u m levels. 3~ Finally, a c o m p a r i s o n of IV a n d IO d i a z e p a m i n c o n t r o l l i n g pentylenetetrazol-induced epileptogenic activity in pigs showed no t i m e difference to a b o l i s h s e i z u r e act i v i t y or d i f f e r e n c e i n d i a z e p a m levels.33 T h e u s e of t h i s t e c h n i q u e h a s b e e n r e c e i v i n g press i n t h e p a r a m e d i c litera t u r e 34-36 a n d h a s g a i n e d w i d e s p r e a d favor a m o n g t h e p r e h o s p i t a l E M T a n d flight n u r s e p e r s o n n e l i n o u r c o m m u nity. T h e r e are several r e p o r t s of training p r o g r a m s c u r r e n t l y i n s t r u c t i n g inexperienced medical and prehospital h e a l t h care w o r k e r s i n t h i s m e t h o d a n d a c h i e v i n g h i g h s u c c e s s rates.g7, g8 T h e e s t a b l i s h m e n t of a p e r i p h e r a l 1V r e m a i n s t h e f i r s t v a s c u l a r a c c e s s of choice. A r e c e n t r e p o r t b y K a n t e r et a139 p r o p o s e d t h a t a b o n e m a r r o w inf u s i o n b e a t t e m p t e d a f t e r five m i n u t e s i n t o a r e s u s c i t a t i o n if t h e r e w a s u n s u c c e s s f u l c a n n u l a t i o n of a p e r i p h e r a l vein. We feel t h a t a n IO i n f u s i o n is t h e n e x t m o s t logical step for t h e definit i v e d e l i v e r y of f l u i d s a n d drugs. Indeed, t h i s r a t i o n a l e h a s b e e n p r o p o s e d previously. 40 It h a s b e e n s h o w n t h a t the technique can deliver adequate a m o u n t s of fluids, p r o v i d e a n effective a v e n u e for d r u g delivery, c a n b e easily m a s t e r e d b y all m e m b e r s of t h e EMS system, and could potentially shorten scene times. Our study had several limitations. T h e n u m b e r of p a t i e n t s s t u d i e d w a s

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very small, and the patients were s t u d i e d r e t r o s p e c t i v e l y b y c h a r t review. T h e c l i n i c i a n s c a r i n g for t h e patients may not have been seeking c o m p l i c a t i o n s of IO i n f u s i o n , a n d t h u s the complication rate may have been falsely low. F u r t h e r m o r e , m o s t of t h e p a t i e n t s did n o t s u r v i v e a n d t h e r e f o r e there may not have been time for complications to be noted. Although IO i n f u s i o n appears safe, it w i l l t a k e p r o s p e c t i v e s t u d i e s w i t h m u c h larger n u m b e r s to a n s w e r t h i s q u e s t i o n definitively. CONCLUSION T h e IO t e c h n i q u e h a s b e e n p r o v e n in both animal models and isolated human reports to be an effective m e t h o d of fluid a n d drug delivery. Paramedics can be easily instructed in this method with subsequent implementation in the field. While the n u m b e r of c a s e s i n t h i s r e p o r t is small, w e e x p e r i e n c e d a h i g h degree of success. We r e c o m m e n d t h i s a l t e r n a tive to v a s c u l a r access i n c r i t i c a l l y ill pediatric patients when initial att e m p t s at p e r i p h e r a l IV i n s e r t i o n are n o t successful. REFERENCES 1. Friesen RM, Duncan P, Tweed WA, et al: Ap t praisal of pediatric cardiopulmonary resuscitation. Can Med Assoc J i982;126:1055-1058.

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istration (abstract). Ann Emerg Med 1986;15: 644. 32. Brickman K, Rega P, Guinness M: A comparative study of intraosseous versus intravenous infusion of phenobarbital (abstract). Ann Emerg Med 1986;15:644. 33. Spivey WH, Unger HD, Lathers CM, et al: intraosseous diazepam suppression of pentylenetetrozol-induced epileptogenic activity in pigs. Ann Emerg Med 1987;16:156-159. 34. Friery J, Weiner K: Start an IV in that bone.

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