All posts by TheTraumaPro

Air Embolism From an Intraosseous (IO) Line

IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

The “Double-Barrel” IO: Can It Work?

Intraosseous lines (IO) make life easy. They are quicker to insert, have a higher success rate, and require less experience than a standard IV. And they can be used for pretty much any solution or drug that can be given through an IV.

But there are some limitations. They can’t be inserted into a fractured bone. The manufacturer cautions against multiple insertions into the same bone. A second insertion should not be performed in the same bone within 48 hours. 

But, as with so many things in medicine, there is little in the way of proof for these assertions. They seem like good ideas for precautions, but that does not mean they are correct. No real research has been done in this area. Until now.

The concept of using two IO needles in one bone was explored in an animal model by researchers in Canada. They used a swine model (using the foreleg/humerus, to be exact), and tested several infusion setups.

Here are the factoids: 

  • Infusing crystalloid using an infusion pump set to 999ml/hr took 30 minutes with a single IO, and 15 minutes with a “double-barrel” setup
  • Giving crystalloid using a pressure bag set at 300 mm/Hg took 24 minutes with a single IO, and 23 minutes with double the fun
  • The double-barrel setup also worked for a blood/drug combo. 250cc of blood and 1 gm of TXA in 100ml of saline infused via pump in 13 minutes.
  • Simultaneous anesthesia drugs (ketamine infusion in IO #1, fentanyl and rocuronium bolus in IO #2) without problems
  • Multiple fluid + drug infusion combinations were tested without incident
  • There were no needle dislodgements, soft tissue injuries, fractures, or macrohistologic damage to the bone or periosteum

Bottom line: Remember, these are pigs. Don’t do this in humans yet. However, this is pretty compelling evidence that the double-barrel IO concept will work in people. And it appears that infusion pumps must be used for effective, fast infusions. I recommend that prehospital agencies with inquiring minds set up a study in people to prove that this works in us, too.

Related posts:

Reference: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury, in press April 30, 2015.

Trauma Education: The Next Generation Coming Soon!

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TE:TNG, version 3.0 is coming soon! Our fast-paced 4 hour program will be available again live this year (but you have to come see me in St. Paul MN), or via LiveStream on Thursday, September 17.

Our guest speaker is Dr. Brian Lin, author of the Closing the Gap – lacerationrepair.com website, talking about “Advanced wound closure tips and tricks.”

We also have a number of other live presenters, delivering 20 minute fact-packed talks on trauma topics applicable to all trauma professionals. Topics include:

  • Top 10 Pearls of Palliative Care in Trauma
  • For Level III centers: How to keep more trauma patients at your hospital
  • De-escalation and takedown in the ED

Peppered among all the live presenters will be curbside consults, where we ask the specialists what you also wished you had asked. We’ll also show a variety of focused, 5 minute how-to videos on:

  • Using ultrasound to start peripheral IVs
  • Stabilizing prior to transfer
  • Small bore chest tubes
  • And more!

For more information, or to make arrangements to join us live or electronically, please visit our website at www.tetng.org

I’m looking forward to “seeing” you there!

Michael

Trauma MedEd Newsletter Released To Subscribers Next Week!

The August Trauma MedEd Newsletter will be released to subscribers on September 1. This month is the annual “Potpourri” issue. Articles include:

  • Crowdfunding research
  • Thoughts on TEG/ROTEM
  • Thoughts on REBOA
  • And more!

Anyone on the subscriber list as of midnight (CST) on August 31 will receive it the next day. Everybody else will have to wait for me to release it here the following week. So sign up for early delivery now by clicking here!

And did you catch all the malpractice articles in the last two issues?

Pick up back issues here!