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Intraosseous vascular access in disasters and mass casualty events: A review of the literature

James M. Burgert, DNAP

Abstract


Objective: The intraosseous (IO) route of vascular access has been increasingly used to administer resuscitative fluids and drugs to patients in whom reliable intravenous (IV) access could not be rapidly or easily obtained. It is unknown that to what extent the IO route has been used to gain vascular access during disasters and mass casualty events. The purpose of this review was to examine the existing literature to answer the research question, “What is the utility of the IO route compared to other routes for establishing vascular access in patients resulting from disasters and mass casualty events?”

Design: Keyword-based online database search of PubMed, CINAHL, and the Cochrane Database of Systematic Reviews.

Setting: University-based academic research cell.

Evidence Sources: Included evidence were randomized and nonrandomized trials, systematic reviews with and without meta-analysis, case series, and case reports. Excluded evidence included narrative reviews and expert opinion.

Main Outcome Measures: Not applicable.

Results: Of 297 evidence sources located, 22 met inclusion criteria. Located evidence was organized into four categories including chemical agent poisoning, IO placement, while wearing chemical protective clothing (PPE), military trauma, and infectious disease outbreak.

Conclusions: Evidence indicates that the IO route of infusion is pharmacokinetically equal to the IV route and superior to the intramuscular (IM) and endotracheal routes for the administration of antidotal drugs in animal models of chemical agent poisoning while wearing full chemical PPE. The IO route is superior to the IM route for antidote administration during hypovolemic shock. Civilian casualties of explosive attacks and mass shootings would likely benefit from expanded use of the IO route and military resuscitation strategies. The IO route is useful for fluid resuscitation in the management of diarrheal and hemorrhagic infectious disease outbreaks.


Keywords


chemical agent poisoning, explosive attack, infectious disease epidemic, intraosseous, mass shooting, resuscitation

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References


Greenough G, McGeehin M, Bernard SM, et al.: The potential impacts of climate variability and change on health impacts of extreme weather events in the United States. Environ Health Perspect. 2001; 109(suppl 2): 191-198.

Sauerborn R, Ebi K: Climate change and natural disasters—Integrating science and practice to protect health. Global Health Action. 2012; 5: 1-7.

Bell E: Readying health services for climate change: A policy framework for regional development. Am J Public Health. 2011; 101(5): 804-813.

Costello A, Abbas M, Allen A, et al.: Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009; 373(9676): 1693-1733.

The White House: National Security Strategy. Washington, DC: US Government Printing Office, 2015: 1-29.

National Science and Technology Council, Committee on Homeland and National Security: A National Strategy for CBRNE Standards. Washington, DC: US Government Printing Office, 2011: 2-6.

Cil Y, Simsek HA, Yildiz H: Primary intraosseous cavernous hemangioma of the toe. Musculoskelet Surg. 2013; 97(3): 259-261.

Timboe HL, Bruttig SP, Ruemmler MW: Adult IO in the combat zone: The past, present and future use of intraosseous infusion by the U.S. military. JEMS. 2005; 30(10)(suppl): 27-28.

Wright C, Mahoney P, Hodgetts T, et al.: Fluid resuscitation: A Defence Medical Services Delphi study into current practice. J R Army Med Corps. 2009; 155(2): 99-104.

Okumura T, Hisaoka T, Naito T, et al.: Acute and chronic effects of sarin exposure from the Tokyo subway incident. Environ Toxicol Pharmacol. 2005; 19(3): 447-450.

Warrick J: More than 1,400 killed in Syrian chemical weapons attack, U.S. says. The Washington Post. August 30, 2013. Available at https://www.washingtonpost.com/world/national-security/nearly-1500-killed-in-syrian-chemical-weapons-attack-us-says/2013/08/30/b2864662-1196-11e3-85b6-d27422650fd5_story.html. Accessed March 9, 2016.

BBC News: Samples ‘confirm IS used mustard agent in Iraq attack’. BBC World News. February 15, 2016. Available at http://www.bbc.com/news/world-middle-east-35582861. Accessed March 9, 2016.

Alfred C: 20 years ago, A shadowy cult poisoned the Tokyo subway. The Huffington Post. March 20, 2015. Available at http://www.huffingtonpost.com/2015/03/20/tokyo-subway-sarin-attack_n_6896754.html. Accessed March 9, 2016.

Newmark J: The birth of nerve agent warfare: Lessons from Syed Abbas Foroutan. Neurology. 2004; 62(9): 1590-1596.

Vardi A, Berkenstadt H, Levin I, et al.: Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: Proposed alteration of treatment protocol. Anesth Analg. 2004; 98(6): 1753-1758.

Prete MR, Hannan CJ Jr, Burkle FM Jr: Plasma atropine concentrations via intravenous, endotracheal, and intraosseous administration. Am J Emerg Med. 1987; 5(2): 101-104.

Eisenkraft A, Gilat E, Chapman S, et al.: Efficacy of the bone injection gun in the treatment of organophosphate poisoning. Biopharm Drug Dispos. 2007; 28(3): 145-150.

Borron SW, Arias JC, Bauer CR, et al.: Hemodynamics after intraosseous administration of hydroxocobalamin or normal saline in a goat model. Am J Emerg Med. 2009; 27(9): 1065-1071.

Murray DB, Eddleston M, Thomas S, et al.: Rapid and complete bioavailability of antidotes for organophosphorus nerve agent and cyanide poisoning in minipigs after intraosseous administration. Ann Emerg Med. 2012; 60(4): 424-430.

Bebarta VS, Pitotti RL, Boudreau S, et al.: Intraosseous versus intravenous infusion of hydroxocobalamin for the treatment of acute severe cyanide toxicity in a Swine model. Acad Emerg Med. 2014; 21(11): 1203-1211.

Hill SL, Thomas SH, Flecknell PA, et al.: Rapid and equivalent systemic bioavailability of the antidotes HI-6 and dicobalt edetate via the intraosseous and intravenous routes. Emerg Med J. 2015; 32(8): 626-631.

Yost J, Baldwin P, Bellenger S, et al.: The pharmacokinetics of intraosseous atropine in hypovolemic swine. Am J Disaster Med. 2015; 10(3): 217-222.

Uwaydah NI, Hoskins SL, Bruttig SP, et al.: Intramuscular versus intraosseous delivery of nerve agent antidote pralidoxime chloride in Swine. Prehosp Emerg Care. 2016; 20(4): 485-492.

Ben-Abraham R, Gur I, Vater Y, et al.: Intraosseous emergency access by physicians wearing full protective gear. Acad Emerg Med. 2003; 10(12): 1407-1410.

Borron SW, Arias JC, Bauer CR, et al.: Intraosseous line placement for antidote injection by first responders and receivers wearing personal protective equipment. Am J Emerg Med. 2011; 29(4): 373-381.

Castle N, Owen R, Hann M, et al.: Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low- and high-dexterity airway and vascular access skills. Resuscitation. 2009; 80(11): 1290-1295.

Lamhaut L, Dagron C, Apriotesei R, et al.: Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation. 2010; 81(1): 65-68.

Suyama J, Knutsen CC, Northington WE, et al.: IO versus IV access while wearing personal protective equipment in a HazMat scenario. Prehosp Emerg Care. 2007; 11(4): 467-472.

Elster EA, Butler FK, Rasmussen TE: Implications of combat casualty care for mass casualty events. JAMA. 2013; 310(5): 475-476.

Kauvar DS, Lefering R, Wade CE: Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006; 60(6)(suppl): S3-S11.

Schafer N, Driessen A, Frohlich M, et al.: Diversity in clinical management and protocols for the treatment of major bleeding trauma patients across European level I Trauma Centres. Scand J Trauma Resusc Emerg Med. 2015; 23(1): 74.

Santos D, Carron PN, Yersin B, et al.: EZ-IO intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation. 2013; 84(4): 440-445.

Navarro Suay R, Bartolome Cela E, Hernandez Abadia de Barbara A, et al.: Intraosseous access for fluid therapy in combat situations: Use by Spanish military medical staff in Afghanistan. Rev Esp Anestesiol Reanim. 2011; 58(2): 85-90.

Harcke HT, Crawley G, Mabry R, et al.: Placement of tibial intraosseous infusion devices. Mil Med. 2011; 176(7): 824-827.

Harcke HT, Crawley G, Mazuchowski E: Feedback to the field: An assessment of sternal intraosseous (IO) infusion. J Spec Oper Med. 2011; 11(1): 23-26.

Pozza M, Lunardi F, Pflipsen M: Emergency intraosseous access: A useful, lifesaving device used in Afghanistan. J Spec Oper Med. 2013; 13(1): 25-28.

Nadler R, Gendler S, Chen J, et al.: The Israeli Defense Force experience with intraosseous access. Mil Med. 2014; 179(11): 1254-1257.

Lewis P, Wright C: Saving the critically injured trauma patient: A retrospective analysis of 1000 uses of intraosseous access. Emerg Med J. 2015; 32(6): 463-467.

Watson JT, Gayer M, Connolly MA: Epidemics after natural disasters. Emerg Infect Dis. 2007; 13(1): 1-5. Available at http://wwwnc.cdc.gov/eid/article/13/1/06-0779. Accessed April 4, 2016.

Narain JP: Unravelling the health impact of climate change. Indian J Med Res. 2016; 143(1): 1-3.

Orlowski JP: My kingdom for an intravenous line. Am J Dis Child. 1984; 138(9): 803.

Paterson ML, Callahan CW: The use of intraosseous fluid resuscitation in a pediatric patient with Ebola virus disease. J Emerg Med. 2015; 49(6): 962-964.

Meyers L, Frawley T, Goss S, et al.: Ebola virus outbreak 2014: Clinical review for emergency physicians. Ann Emerg Med. 2015; 65(1): 101-108.

Ker K, Tansley G, Beecher D, et al.: Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease. Cochrane Database Syst Rev. 2015; 2: Cd011386.

Barlow B, Kuhn K: Orthopedic management of complications of using intraosseous catheters. Am J Orthop. 2014; 43(4): 186-190.

Leidel BA, Kirchhoff C, Bogner V, et al.: Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012; 83(1): 40-45.

Lairet J, Bebarta V, Lairet K, et al.: A comparison of proximal tibia, distal femur, and proximal humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model. Prehosp Emerg Care. 2013; 17(2): 280-284.

Rush S, D'Amore J, Boccio E: A review of the evolution of intraosseous access in tactical settings and a feasibility study of a human cadaver model for a humeral head approach. Mil Med. 2014; 179(8): 24-28.

Levitan RM, Bortle CD, Snyder TA, et al.: Use of a battery-operated needle driver for intraosseous access by novice users: Skill acquisition with cadavers. Ann Emerg Med. 2009; 54(5): 692-694.

Bailey H: Bone marrow as a site for the reception of infusions, transfusion, and anaesthetic agents: A review of the present position. Anesthesiology. 1944; 5(9): 545-546.

Chapleau W, Al-khatib J, Haskin D, et al.: Advanced trauma life support (ATLS®): The ninth edition. J Trauma Acute Care Surg. 2013; 74(5): 1363-1366.

Neumar RW, Otto CW, Link MS, et al.: Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122(18)(suppl 3): S729-S767.

Care CoTCC: Tactical Combat Casualty Care Guidelines, 2014. Available at http://www.health.mil/Libraries/120917_TCCC_Course_Materials/TCCC-Guidelines-120917.pdf. Accessed March 22, 2016.

Cooper BR, Mahoney PF, Hodgetts TJ, et al.: Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. J R Army Med Corps. 2007; 153(4): 314-316.

Chatfield-Ball C, Boyle P, Autier P, et al.: Lessons learned from the casualties of war: Battlefield medicine and its implication for global trauma care. J R Soc Med. 2015; 108(3): 93-100.

Vassallo J, Horne S, Smith JE: Intraosseous access in the military operational setting. J R Nav Med Serv. 2014; 100(1): 34-37.

Haider AH, Piper LC, Zogg CK, et al.: Military-to-civilian translation of battlefield innovations in operative trauma care. Surgery. 2015; 158(6): 1686-1695.

Jacobs LM Jr: The Hartford consensus IV: A call for increased national resilience. Conn Med. 2016; 80(4): 239-244.

Abaci HE, Shuler ML: Human-on-a-chip design strategies and principles for physiologically based pharmacokinetics/pharmacody namics modeling. Integr Biol. 2015; 7(4): 383-391.

Singh S, Aggarwal P, Lodha R, et al.: Feasibility study of a novel intraosseous device in adult human cadavers. Indian J Med Res. 2016; 143(3): 275-280.




DOI: https://doi.org/10.5055/ajdm.2016.0235

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