Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment

Lamhaut, Lionel; Dagron, C.; Apriotesei, R.; Gouvernaire, J.; Elie, Caroline; Marx, J.-S.; Télion, C.; Vivien, Benoît; Carli, Pierre

doi:10.1016/j.resuscitation.2009.09.011

Cited by 45 publications

(52 citation statements)

References 20 publications

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“…6,11 Intraosseous (IO) infusion, a well-established method of medication and fluid delivery, has been advocated as a reliable substitute for resuscitation for mass casualty incidents and first responders. 12 It can be performed with minimal skill, has few adverse effects, and has an infusion time similar to central venous access. [13][14][15] It has also been studied for hydroxocobalamin administration and has a similar pharmacokinetic profile and feasibility to IV infusion in large animal models.…”

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confidence: 99%

Intraosseous Versus Intravenous Infusion of Hydroxocobalamin for the Treatment Of Acute Severe Cyanide Toxicity in a Swine Model

Bebarta

Pitotti

Boudreau

et al. 2014

Academic Emergency Medicine

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Objectives: Easily administrated cyanide antidotes are needed for first responders, military troops, and emergency department staff after cyanide exposure in mass casualty incidents or due to smoke inhalation during fires involving many victims. Hydroxocobalamin has proven to be an effective antidote, but cannot be given intramuscularly because the volume of diluent needed is too large. Thus, intraosseous (IO) infusion may be an alternative, as it is simple and has been recommended for the administration of other resuscitation drugs. The primary objective of this study was to compare the efficacy of IO delivery of hydroxocobalamin to intravenous (IV) injection for the management of acute cyanide toxicity in a well-described porcine model. Methods:Twenty-four swine (45 to 55 kg) were anesthetized, intubated, and instrumented with continuous mean arterial pressure (MAP) and cardiac output monitoring. Cyanide was continuously infused until severe hypotension (50% of baseline MAP), followed by IO or IV hydroxocobalamin treatment. Animals were randomly assigned to receive IV (150 mg/kg) or IO (150 mg/kg) hydroxocobalamin and monitored for 60 minutes after start of antidotal infusion. The primary outcome measure was the change in MAP after antidotal treatment from onset of hypotension (time zero) to 60 minutes. A sample size of 12 animals per group was determined by group size analysis based on power of 80% to detect a one standard deviation of the mean MAP between the groups with an alpha of 0.05. Whole blood cyanide, lactate, pH, nitrotyrosine (nitric oxide marker) levels, cerebral and renal near infrared spectrometry (NIRS) oxygenation, and inflammatory markers were also measured. Repeated-measures analysis of variance was used to determine statistically significant changes between groups over time.Results: At baseline and at the point of hypotension, physiologic parameters were similar between groups. At the conclusion of the study, 10 out of 12 animals in the IV group and 10 out of 12 in IO group survived (p = 1.0). Both groups demonstrated a similar return to baseline MAP (p = 0.997). Cardiac output, oxygen saturation, and systemic vascular resistance were also found to be similar between groups (p > 0.4), and no difference was detected between bicarbonate, pH, and lactate levels (p > 0.8). Cyanide levels were undetectable after the hydroxocobalamin infusion throughout the study in both groups (p = 1.0). Cerebral and renal NIRS oxygenation decreased in parallel to MAP during cyanide infusion and increased after antidote infusion in both groups. Serum nitrotyrosine increased during cyanide infusion in all animals and then decreased in both study arms after hydroxocobalamin infusion (p > 0.5). Serum cytokines increased starting at cyanide infusion and no difference was detected between groups (tumor necrosis factor-a, interleukin [IL]-1b, IL-6, and IL-10).

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confidence: 99%

Intraosseous Versus Intravenous Infusion of Hydroxocobalamin for the Treatment Of Acute Severe Cyanide Toxicity in a Swine Model

Bebarta

Pitotti

Boudreau

et al. 2014

Academic Emergency Medicine

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“…Les auteurs concluent donc que le KTIO doit être considéré comme l'accès vasculaire de première intention chez les victimes de catastrophe NRBC. Ces résultats sont appuyés par l'étude de Lamhaut et al [15] qui retrouvait que l'abord vasculaire par voie intraosseuse était significativement plus court que la VVP (65 ± 17 vs 104 ± 30 secondes). Il en est de même pour l'étude de Suyama et al [17] qui retrouvait une différence significative sur l'accès veineux en tenue et sans tenue et un intérêt statistiquement significatif à utiliser le KTIO (52 vs 104 secondes).…”

Section: Discussionunclassified

“…Pour la pose de VVP, un bras de perfusion multiveine adulte Laerdal ® précédemment validé dans des études de simulation était utilisé [15]. Le bras de perfusion permettait la palpation et la désinfection du site de ponction choisi, la cathétérisation au niveau des réseaux veineux du dos de la main, radial, céphalique, médian et basilique, et des injections intraveineuses en bolus ou en perfusion lente.…”

Section: Matériel Et Méthodesunclassified

“…Pour la pose de KTIO étaient utilisés un tibia de perfusion de type Laerdal ® , des compresses stériles 5 cm × 5 cm, un flacon d'antiseptique, une perceuse EZ-IO™ Vidacare (Teleflex Medical Europe, Dublin, Irlande), une aiguille taille adulte calibre 15 G, une seringue de 20 ml préremplie, un Les études ayant analysé la difficulté des gestes techniques liée au port de tenues de protection des risques radiologiques ou chimiques rapportent une augmentation de délai d'insertion d'accès veineux de 50 à 100 % [7]. En supposant l'hypothèse d'un délai d'accès veineux sur mannequin sans habillage de 70 ± 30 secondes [15], 22 participants étaient nécessaires pour démontrer une augmentation significative du délai d'accès veineux périphérique de plus de 50 % en tenue de protection individuelle Ebola pour une puissance de 80 %.…”

Section: Matériel Et Méthodesunclassified

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Faisabilité des gestes d’urgence en tenue de protection individuelle du virus Ebola : pose d’abords vasculaires et contrôle des voies aériennes supérieures sur mannequin

Bosc

Sanchez

Carrié

et al. 2016

Ann. Fr. Med. Urgence

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Objectif : Les équipes prenant en charge un patient suspect de virose Ebola sont tenues au port d'équipements de protection individuelle (EPI) susceptibles d'entraver la dextérité des opérateurs. L'objectif principal est d'étudier l'impact des EPI Ebola sur la difficulté et le délai de réalisa-tion des gestes d'urgence. Matériel et méthodes : Cette étude observationnelle monocentrique croisée incluait 22 médecins urgentistes, réanima-teurs ou infirmiers -anesthésistes volontaires devant réali-ser cinq ateliers sur mannequin avec ou sans port d'EPI Ebola selon une séquence prédéterminée : voie veineuse périphérique (VVP), cathéter intraosseux (KTIO), intubation avec et sans Eschmann ou après pose de LMA-Fastrach™. Le critère de jugement principal était le délai de réalisation des gestes techniques avec et sans port d'EPI. Résultats : Le port de l'EPI n'augmente pas le taux d'échec de chaque geste technique mais augmente significativement les délais d'intubation simple (29 vs 36 secondes ; p < 0,01), d'intubation avec Eschmann (38 vs 45 secondes ; p = 0,03) et l'intubation au LMA-Fastrach™ (39 vs 45 secondes ; p < 0,001). Le port d'EPI Ebola augmentait la difficulté ressentie pour la pose d'abords vasculaires sans augmenter le taux d'échec ni modifier les délais de pose de VVP. Le recours au KTIO était plus rapide que la pose de VVP sans (67 vs 88 secondes ; p = 0,02) et avec tenue (78 vs 101 secondes ; p < 0,01). Conclusion : Le port de l'EPI n'entraîne qu'un impact modéré sur la dextérité des gestes techniques en situation d'urgence. Ces résultats doivent être confortés par des études cliniques. Mots clés Ebola · Équipement de protection individuelle · Voie veineuse · Cathéter intraosseux · IntubationAbstract Background: Emergency or critical care physicians dealing with patients with Ebola virus disease (EVD) have to handle technical skills while wearing specific personal protective equipment (PPE). We thus aimed to assess the impact of Ebola-PPE for the completion of five emergency technical skills on training manikin. Methods: Twenty-two volunteers were recruited to perform intubation with and without Eschmann tube, LMAFastrach™ placement, insertion of an intravenous (IV) cannula and intra-osseous (IO) during a predefined sequence. The main endpoint was the time for completion of the five technical skills on manikin with and without Ebola-PPE in a random order. Results: The success rate of the five technical skills whilst wearing Ebola-PPE was equivalent but significantly increased the time for simple intubation (29 vs 36 s; P < 0.01), intubation with Eschmann (38 vs 45 s ; P = 0.03) and LMA-Fastrach™ placement (39 vs 45 s; P < 0.001). Wearing Ebola-PPE increased difficulty for vascular access without increasing the failure rate or change the time of installation VVP. IO insertion was faster than IV insertion access without PPE (67 vs 88 s; P = 0.02) and with PPE (78 vs 101 s; P = 0.007).

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“…[42][43][44] However, IV access may delay treatment and prolong scene time. 45 Skill in obtaining IV and IO access can improve with simulation, 46,47 and providers may benefit from continuing education for skill maintenance.…”

Section: Procedures: IV Accessmentioning

confidence: 99%

An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology

Shah¹,

Macias²,

Dayan³

et al. 2013

Prehospital Emergency Care

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Objective. The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence. Methods. A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formu- The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions. Results. Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if <60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route. Conclusions. Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.

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Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment

Cited by 45 publications

References 20 publications

Intraosseous Versus Intravenous Infusion of Hydroxocobalamin for the Treatment Of Acute Severe Cyanide Toxicity in a Swine Model

Intraosseous Versus Intravenous Infusion of Hydroxocobalamin for the Treatment Of Acute Severe Cyanide Toxicity in a Swine Model

Faisabilité des gestes d’urgence en tenue de protection individuelle du virus Ebola : pose d’abords vasculaires et contrôle des voies aériennes supérieures sur mannequin

An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology

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