Intraosseous Needle Research Articles

Temporising extradural haematoma by craniostomy using an intraosseous needle

We report a novel application of intraosseous needle drainage, alleviating raised intracranial pressure due to extradural haematoma. The potential application of this technique in preventing secondary brain injury and herniation during transfer to a neurosurgical unit is discussed.

Compartment syndrome- A rare complication of intraosseous access in adult patients

Background: Intraosseous (IO) access are being widely used in resuscitation of patients with difficult intra-venous (IV) access. The United Kingdom Resuscitation Council guidelines recommend the use of IO access, after two minutes of failed IV access in adult patients or two failed IV attempts in pediatric patients. There are various complications associated with IO access such as extravasation of the infusion fluid or medications, bleeding, infection and pain1. Compartment syndrome is a rare complication associated with IO access. This is reported commonly in children where in certain cases the affected limb required amputation. We report a case where an adult patient developed compartment syndrome secondary to IO access. Methods: A 52-year-old lady who was on dialysis for renal failure presented to the Emergency Department (ED) with septic shock. She was in peri-arrest and had a difficult IV access. Therefore an IO needle was inserted to her right tibia and resuscitation was carried out with fluids and medications. She required emergency intubation and ventilation and was later admitted to the Intensive Care Unit (ICU). The following day, it was found that she developed a compartment syndrome of the right lower leg where she had the IO access. Results: Patient was taken to the theatre for an urgent fasciotomy of the affected leg by the orthopedic surgeons with input from plastic surgeons. She made a steady but full recovery and was discharged home later. Conclusions: Compartment syndrome is a rare complication of IO access (0.6%) 1. Careful monitoring of the IO site is recommended. It is advisable to remove the IO needle once a definitive IV access is established. 1. Complication with Intraosseous Access: Scandinavian Users' Experience. Hallas et al. West J Emerg Med. 2013 Sep; 14(5): 440–443.

Advances in military resuscitation

Trauma is a leading cause of death and disability worldwide, in civilian environments and on the battlefield. Trauma-induced haemorrhage is the principal cause of potentially preventable death, which is generally attributable to a combination of vascular injury and coagulopathy. Survival rates following severe traumatic injury have increased due to advanced trauma management initiatives and treatment protocols, influenced by lessons learned from recent conflicts in Iraq and Afghanistan.The use of tourniquets and intraosseous needles, early blood and blood product transfusion, administration of tranexamic acid in pre-hospital settings, and consultant-led damage control resuscitation incorporating damage control surgery have all played their part. All are quantified by trauma governance processes, including a robust trauma registry. Some of the lessons learned in combat are equally applicable to civilian environments, and this article describes several of the most important of these. It also gives an overview of advancements in UK military trauma management of severely injured combat casualties, honed over a decade of conflict.

Advances in military resuscitation.

Trauma is a leading cause of death and disability worldwide, in civilian environments and on the battlefield. Trauma-induced haemorrhage is the principal cause of potentially preventable death, which is generally attributable to a combination of vascular injury and coagulopathy. Survival rates following severe traumatic injury have increased due to advanced trauma management initiatives and treatment protocols, influenced by lessons learned from recent conflicts in Iraq and Afghanistan. The use of tourniquets and intraosseous needles, early blood and blood product transfusion, administration of tranexamic acid in pre-hospital settings, and consultant-led damage control resuscitation incorporating damage control surgery have all played their part. All are quantified by trauma governance processes, including a robust trauma registry. Some of the lessons learned in combat are equally applicable to civilian environments, and this article describes several of the most important of these. It also gives an overview of advancements in UK military trauma management of severely injured combat casualties, honed over a decade of conflict.

Intraosseous Infusion as a Bridge to Definitive Access

Intraosseous (IO) needle placement is an alternative for patients with difficult venous access. The purpose of this retrospective study was to examine indications and outcomes associated with IO use at a Level 1 trauma center (January 2008-May 2015). Data points included demographics, time to insertion, intravenous (IV) access points, indications, infusions, hospital and intensive care unit length of stay, and mortality. Of 68 patients with IO insertion analyzed (63.2% blunt trauma, 29.4% penetrating trauma, and 7.4% medical), 56 per cent were hypotensive on arrival and 38.2 per cent asystolic. The most common indications for IO infusion were difficult IV access (69%) and rapid sequence intubation (20.6%). The median time to IO access was three minutes. IV access was gained after IO in 72.1 per cent of patients. Through IO access, 30.9 per cent patients received crystalloid, 29.4 per cent received Advanced Care Life Support (ACLS) medications, 25 per cent rapid sequence intubation medications, 20.6 per cent blood products, and 2.9 per cent seizure medications. Overall, 80.9 per cent were intubated in the Emergency Department (ED), 26.5 per cent had ED thoracotomy, and 20.6 per cent had a laparotomy. Median crystalloid infused through IO was 180 cc in pediatric patients and 1 L in adults, respectively. Extravasation, the most common complication, was experienced by 7.4 per cent of patients. Inhospital mortality was 72.9 per cent. IO access should be considered when there is a need for rapid intervention requiring vascular access.

Rapid sequence induction via an intraosseous needle.

The use of the intraosseous (IO) route for drug administration has been widely reported in the prehospital and military trauma setting, for use in paediatric patients and for use in the cardiac arrest scenario for rapid access. We wish to highlight its use for rapid sequence induction (RSI) in the adult population in a case of difficult intravenous access. A patient presented to our hospital as a stand-by call to the Emergency Department resuscitation area. He was peri-arrest with cardiogenic shock. He was cyanosed with unrecordable oxygen saturations and blood pressure but was very combative. Intubation to facilitate oxygenation was required urgently due to his rapidly deteriorating condition. Multiple attempts at securing intravenous access had been unsuccessful. An EZ-IO (Prometheus Medical Ltd, Hereford, UK) Intraosseous Vascular Access System was inserted in his right proximal tibia. Rapid sequence induction was performed using fentanyl 200mg, ketamine 100mg and suxamethonium 100mg. No fasciculations were observed. We waited 30 s and attempted direct laryngoscopy, which obtained a Grade I Cormack-Lehane View. Intubation was secured at first attempt. The induction process felt very similar in nature and speed to a standard intravenous induction. Post intubation, rapid intravenous access was secured in the right external jugular and then a femoral central line sited. The intraosseous route for drug administration has been used for many years. Studies comparing the pharmacokinetic data of intraosseous versus central venous drug delivery have primarily been undertaken in animals. One study has compared intraosseous versus intravenous rocuronium in anaesthetised swine. They compared electromyographic data obtained following tibial intraosseous administration to that of peripheral intravenous administration and demonstrated no statistically significant difference in the onset time between the two groups. They also demonstrated that the duration of paralysis with the intraosseous route was longer than with the intravenous. They concluded that rocuronium could be administered via the intraosseous route in the same doses as when using the intravenous route. With regard to human studies, a prospective, randomised crossover study has compared the delivery of intraosseous to intravenous morphine in adults and demonstrated that there was no statistically significant difference in the majority of the pharmacokinetic data including the maximum plasma concentration, time to maximum concentration and area under plasma concentration time curve. The majority of reports of using intraosseous for RSI have come from military and trauma experience. A recent observational study has been published in the Emergency Medicine Journal looking at whether RSI via IO was comparable to the intravenous route in terms of grade of view and number of attempts at intubation. The study demonstrated that in the 34 patients who received RSI via IO for trauma they had a 97% first pass intubation rate and that 91% of patients had a Grade 1 Cormack-Lehane view. They were unable to compare this directly to RSI via the intravenous route, as intraosseous access is often the preferred route of access in a military trauma setting. A further military study retrospectively reviewed 830 adult trauma cases and found that 1014 IO devices were inserted over a 60-month period. They demonstrated that the devices were used to infuse anaesthetic induction drugs, analgesia, tranexamic acid, blood and blood products, and intravenous fluids. Of the 1205 times that the IO route was used to infuse drugs, anaesthetic induction agents were the most common drug given, being used for this purpose in 61.8% of cases. With regard to complications, there were no serious complications reported and 14 minor complications that included failure to correctly place IO device, failure to infuse drug, or fracture of needle. This is similar to a Danish study that looked at complications associated with intraosseous access. They showed that serious complications such as compartment syndrome or osetomyelitis are very rare and that problems such as difficulty penetrating periosteum, difficulty aspirating bone marrow and difficulties injecting or infusing fluids or drugs are more common. One of the concerns with the use of the intraosseous route in awake patients is the side effects of pain on insertion and pain on injection. Reports have

Accuracy of paediatric intraosseous needle placement from post mortem imaging

Abstract Introduction Accurate placement of intraosseous needles (ION) is an important part of emergency paediatric resuscitation. The objective of our study was to assess the accuracy of ION placement through post mortem radiological imaging techniques. Methods We retrospectively reviewed post mortem skeletal surveys (PMSS) performed at our institution in an observational study for the presence or absence of ION on each image of the lower and upper limbs, some of whom had also undergone post mortem CT (PMCT). Placement was documented as correct or incorrect (in soft tissues, through the bone, or within the physis). Results 115/150 ION were correctly sited (76.7%) in 273 complete PMSS reviewed. 23/35 (65.7%) incorrectly sited ION were within the soft tissues of the leg, 8/35 (22.9%) had gone through the bone, and 4/35 (11.4%) were epiphyseal. 43/66 (65.2%) ION were correctly sited on PMCT, with 65.2%, 30.4% and 4.4% within the soft tissues, gone through the bone and epiphyseal respectively. In 5 discrepant cases, PMCT demonstrated inaccurate ION placement which was termed “correct” on PMSS. Conclusions Up to a third of ION found at PM imaging are incorrectly placed and lie mostly within the soft tissues of the leg. We highlight this error rate to educate those placing ION in an emergency situation.

Characteristics of Children Who Undergo Intraosseous Needle Placement.

Intraosseous (IO) access is a standard of care for pediatric emergencies in the absence of conventional intravenous access. Intraosseous needles provide access for resuscitation fluids and medications and are often placed in the emergency department. However, there are no studies to date that describe the characteristics of pediatric IO needle recipients or their dispositions and outcomes. This study examined the characteristics and disposition of children following IO needle placement by prehospital and emergency room teams before being transported to a children's hospital. We conducted a retrospective descriptive analysis of pediatric patients who had an IO needle placed as a part of their transport care. Data was extracted from a Level 1 trauma tertiary care children's hospital transport database from 1993 to 2009. We measured diagnosis, insertion reason, insertion time (day vs. night shift), complications, and disposition of patients after IO needle placement. There were 143 eligible patients in the study; 65% were males. Mean patient's age was 1.2 years (range: 0.01-13 years). Intraosseous needles were placed most often for patients with cardiopulmonary compromise. Of the 143 patients transported, 53% (n = 76) were placed for no intravenous access and 34% (n = 49) were placed for nonperfusing rhythm. The majority of the IO needles were placed during the daytime (0700-1900 hr), and most patients experienced no complications (n = 67; 47%). However, of those who experienced a complication, 27% were due to infiltration of the IO needle. Of those admitted to hospital, 58% (n = 83) were ultimately discharged home. Intraosseous access provides a safe and reliable method for rapidly achieving a route for administration of medications, fluids and blood products. It is a lifesaving measure with most IO needles successfully placed by referring facilities prior to transport, with few reported complications.

240 An Observational Review of Pediatric Intraosseous Needle Placement in the Pediatric Emergency Department

240 An Observational Review of Pediatric Intraosseous Needle Placement in the Pediatric Emergency Department

Paediatric vascular access

### Key points Obtaining reliable vascular access in small children is frequently made challenging by anatomical factors—in particular, small, mobile veins and an excess of subcutaneous fat which make visualization and palpation of veins difficult. Paediatric patients are often less co-operative, and the potential for psychological trauma, especially with repeated procedures in the conscious patient, further complicates matters. Short-term vascular access is frequently required in hospitalized children for the delivery of i.v. fluids, medication, and blood product administration. Longer-term vascular access devices are required for repeated medication delivery (e.g. enzyme replacement therapy in inherited metabolic diseases), chemotherapy, immunotherapy, total parenteral nutrition, and extracorporeal procedures such as plasmapheresis and haemodialysis. In addition, vascular access devices may be needed for repeated blood sampling and invasive haemodynamic monitoring. The choice of vascular access device depends upon the condition and preference of the patient or parent/guardian, the likely duration and frequency of treatment, and the properties of the infusate. Infusates with vesicant properties (drugs with the potential to cause blistering with tissue injury, e.g. calcium solutions and amphotericin B), hypertonic solutions, and those with pH 9 will necessitate central venous access. Vasopressors and inotropes are preferentially administered centrally as they require reliable access and extravasation may cause tissue necrosis. It is important to try to predict future needs for vascular access as poor prospective management …

Military-to-civilian translation of battlefield innovations in operative trauma care

Historic improvements in operative trauma care have been driven by war. It is unknown whether recent battlefield innovations stemming from conflicts in Iraq/Afghanistan will follow a similar trend. The objective of this study was to survey trauma medical directors (TMDs) at level 1-3 trauma centers across the United States and gauge the extent to which battlefield innovations have shaped civilian practice in 4 key domains of trauma care. Domains were determined by the use of a modified Delphi method based on multiple consultations with an expert physician/surgeon panel: (1) damage control resuscitation (DCR), (2) tourniquet use, (3) use of hemostatic agents, and (4) prehospital interventions, including intraosseous catheter access and needle thoracostomy. A corresponding 47-item electronic anonymous survey was developed/pilot tested before dissemination to all identifiable TMD at level 1-3 trauma centers across the US. A total of 245 TMDs, representing nearly 40% of trauma centers in the United States, completed and returned the survey. More than half (n = 127; 51.8%) were verified by the American College of Surgeons. TMDs reported high civilian use of DCR: 95.1% of trauma centers had implemented massive transfusion protocols and the majority (67.7%) tended toward 1:1:1 packed red blood cell/fresh-frozen plasma/platelets ratios. For the other 3, mixed adoption corresponded to expressed concerns regarding the extent of concomitant civilian research to support military research and experience. In centers in which policies reflecting battlefield innovations were in use, previous military experience frequently was acknowledged. This national survey of TMDs suggests that military data supporting DCR has altered civilian practice. Perceived relevance in other domains was less clear. Civilian academic efforts are needed to further research and enhance understandings that foster improved trauma surgeon awareness of military-to-civilian translation.

Interpretation of intravascular gas on postmortem CT in children

Abstract Introduction The use of post-mortem computed tomography (PMCT) is increasing, but the significance of some findings, such as intravascular gas, remain uncertain. In order to correctly interpret the findings, we provide data on a series of cases in whom intravascular gas was noted on PMCT imaging, to assess whether it correlates with clinical features including type of death (traumatic), resuscitation and postmortem interval. Methods Children Results 46 children, mean age 2 years (range 0 days–15.5 years) were included in the study. 63% (29/46) children demonstrated IV gas postmortem. No relationship was demonstrated between IV gas at PMCT and increasing postmortem interval or traumatic death. IV gas was seen more commonly following resuscitation attempts including intra-osseous needle insertions, although this did not reach statistical significance. Conclusion IV gas is commonly identified on PMCT in children, and may be related to resuscitation rather than putrefaction or decomposition. A better understanding of IV gas on PMCT will help interpret these findings on future studies.

G554(P) Implementation of an integrated inpatient paediatric mortality reduction intervention

Background Based at a University teaching hospital in Northern Ethiopia, the author was placed through Voluntary Services Oversea’s (VSO) as a Paediatric Senior. The department witnesses a high Paediatric mortality rate amongst inpatients (30%, non-neonatal). Ward level care is largely provided by junior doctors (Interns). A gap in knowledge and skills of up-to-date resuscitation practices was identified in this group. Project design The project included an intervention to improve Intern knowledge and skills. The intervention comprised development of a resuscitation protocol package with suitable training. A baseline audit of all Paediatric admissions (excluding neonates) over a three month period provided mortality data including specifics of disease category. This highlighted the conditions with highest rates of mortality at our hospital: severe acute malnutrition, coma, meningitis, congestive heart failure (CHF), hypovolaemic shock and meningitis. The Paediatric senior faculty developed five, locally appropriate, protocols to address the acute management of these conditions plus added three complementary protocols based on those promoted by the Emergency Triage, Assessment and Treatment (ETAT), WHO. The final protocol package included: respiratory distress, hypovolaemic shock, septic shock, coma, CHF, airway emergencies, seizure and cardio-pulmonary resuscitation (CPR). The nuances of acute malnutrition were addressed in each protocol. The package provided readily available, locally appropriate guidelines to provide evidence based information for Interns. The protocol package was implemented with a training programme of all Interns rotating through the Paediatric department during the study period (n = 21, September 6th to December 9th 2011). A full day simulation based training course was developed to introduce the concept and use of the protocol package plus development of key resuscitation skills: bag mask ventilation, CPR plus intra-osseous needle placement. Simulation based scenarios were developed to build on theoretical knowledge provided in short didactic lectures and allow practice of skills. Results 474 patients were admitted in the baseline group and 432 following the intervention. No change was observed for overall mortality (crude OR=0.72, 95% CI 0.40–1.29, p = 0.265). No change was observed in first-24-hour mortality (crude OR 0.97, 95% CI 0.37–2.55, p = 0.959). Total examination scores improved from median 32.6 to 73.5% (p Evaluation Two aspects were evaluated to aid measurement of success. An audit of inpatient admissions was carried out pre and post Intern training. Data was collected from the ward log book and entered into an Excel spreadsheet. The primary and secondary outcomes included crude mortality plus mortality within the first 24 h and were expressed as a percentage of admissions. Odds ratios for these outcomes were calculated using univariable logistic regression. Evaluation of Intern knowledge and skills took place pre- and post-training to assess the impact of the simulation based program. Testing took place in multiple choice format with videos of critically ill children to focus on pattern recognition and triage skills plus a theory paper to assess problem-solving in emergency situations. Procedural skills were tested by direct observation. Trainees were asked to demonstrate skills covered in the course while project coordinators applied a standardised, checklist-based marking tool to evaluate their performance. Median trainee examination scores were calculated as percentage answered correctly and pre- and post-training results were compared by Wilcoxon matched-pairs signed ranks test. Conclusions Combining care standardisation, management protocols, and simulation-based training did not red uce mortality among non-neonatal Paediatric inpatients in this study. Simulation-based training improved short-term test performance among Ethiopian medical trainees.

An Unusual Complication of Intraosseous Needle Use

Intraosseous (IO) needles are extremely useful tools to gain urgent access to the circulation when more conventional routes are unavailable or unsuccessful. As with any medical procedure, complications can occur. We review the indications for IO usage and illustrate an unusual complication of continued serous drainage following IO needle removal. The drainage was significant enough to require use of a drainage bag. This chronically ill patient developed septic shock, multi-system organ failure, renal failure and a high catabolic state. As he did not fully tolerate enteric tube feeds, it was not possible to maintain adequate serum albumin. The resultant lower colloid oncotic pressure contributed to the chronic serous leak from the IO site. Avoidance of such a complication relies on proper IO placement and the ability to maintain adequate nutrition to maintain plasma oncotic pressure. Other complications of IO use are reviewed. J Med Cases. 2015;6(2):98-100 doi: http://dx.doi.org/10.14740/jmc2080e

Troponin I can be Determined in Intraosseous Aspirates in a Porcine Shock Model.

Determination of troponin I may be important in the management of the critically ill patient. In medical emergencies, especially when vascular access is difficult to achieve, the use of intraosseous (10) needles is recommended. We aimed to perform a descriptive study, aiming to elucidate whether IO needles can be used to evaluate troponin I in a porcine model of human shock. Eight pigs were anesthetized and challenged with a 6 hours continuous intravenous infusion of E. coli endotoxin. An IO needle (EZ-IO®) was inserted in the proximal tibia of each pig. Circulatory variables were monitored and troponin I was sampled from arterial and venous blood and also from bone marrow aspirates. Circulatory deterioration developed in all endotoxemic animals, which was reflected by a profound deterioration of left ventricular stroke work index. Troponin I levels were nearly identical in both arterial, venous, and IO samples during the first hour of endotoxemia. At 1 hour, all mean troponin I levels had more than doubled as compared to baseline. The troponin I levels continued to increase over time and were markedly elevated versus baseline levels during the 2nd and 6th hours, regardless of sampling site. At 3 hours, IO troponin I reached a plateau, whereas troponin I in both arterial and venous blood continued to increase. This investigation has shown that troponin I can be analyzed in bone marrow aspirates in a shock model. This may be useful in medical emergencies, where cardiac damage is suspected to be involved. The levels of IO troponin I increased during the first 3 hours of shock, after which it remained at a high level. During this initial period there was, in parallel, a progressive circulatory deterioration.

Neonatal cardiovascular emergencies after hospital discharge

Neonates with out-of-hospital cardiovascular emergencies get to Emergency Department or Neonatal Intensive Care Unit in a state of shock, which is a complex clinical syndrome characterized by an acute failure of the circulatory system with inadequate tissue and organ perfusion. It has been demonstrated that early recognition and time-sensitive aggressive resuscitation of neonatal shock significantly reduce mortality and improve outcomes [1]. The update algorithm for goal-directed treatment of neonatal shock emphasizes early use of therapies directed to restore threshold heart rates, normalize blood pressure and capillary refill ≤2 seconds and subsequent intensive hemodynamic support aimed to goals of central venous oxygen saturation (ScvO2) >70% and cardiac index (CI) >3.3 L/min/m2[ 2]. Rapid attainment of a vascular access is pivotal for fluid resuscitation and inotrope therapy and an intraosseous needle must be early inserted especially in the case of cardiac arrest or decompensated shock [3]. Rapid crystalloid boluses of 10-20 ml/kg (over 5-10 minutes) up to 60 ml/kg in the first hour must be administered paying attention to signs of fluid overload because overaggressive therapy can be detrimental in case of cardiogenic shock. An echocardiographic analysis can help clinicians to assess the inferior vena cava diameter or collapsibility as an index of preload status [4] and to evaluate the ventricular size and contractility to identify a cardiogenic shock [5]. Prostaglandin infusion is recommended until a ductal-dependent lesion is ruled out by trained echocardiographists. Empiric antibiotics should be administered within one hour if a sepsis is suspected [6]. Neonates with fluid refractory shock need to start and titrate a peripheral inotropic support and progressively to be added vasopressors according to the hemodynamic state. Many methods are available for the hemodynamic monitoring after the first hour of stabilization of the neonate. A safer ultrasound-guided central venous access can easily be obtained [7] and ScvO2 be measured. The radial arterial pressure monitoring is recommended and the arterial waveform can be used to derive additional hemodynamic information. The monitoring of CI is feasible in neonates only by non-invasive methods such as doppler echocardiography or impedance cardiography [8]. Many aspects of the intensive hemodynamic support of neonatal shock resemble those of paediatric critical care medicine (PCCM) usually provided by anaesthesiologists. We believe that neonatologists need a specific PCCM training before dealing with critically ill neonates and for this purpose our team has devised some courses (Figure ​(Figure1)1) to meet these particular educational and procedural skill needs. Figure 1 Simulation-based training of an ultrasound-guided central venous catheterization. The figure illustrates the ultrasound-guided vessel puncture technique by using phantoms. The trainee visualizes the simulated vessel in transverse scans (short axis) and ...

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.

In the tactical setting, intraosseous (IO) access has become popular to treat hemorrhagic shock when peripheral intravenous access is difficult or impractical. The traditional sites most commonly used by combat medics, corpsmen, and Pararescuemen (PJs) include the sternum and tibial tuberosity. Recent studies have shown that the humeral head (HH) is an appropriate and effective access site for IO infusion and fluid resuscitation in the clinical setting. In this procedural feasibility study, we assessed the ability of 26 U.S. Air Force PJs to perform HH IO placement on fresh, unfixed human cadavers over two consecutive cadaver lab training sessions. Following a formal didactic session, which highlighted proper patient positioning and technique, the PJs were instructed to attempt to place an IO needle using both a drill and manual driver. Once performed, correct placement was reviewed by a physician and confirmed by aspiration of bone marrow. Rates of success were calculated on first and second pass. First pass success rates were 96% and 90.5% for the drill and driver, respectively. Both devices achieved 100% success by the second pass. Military field personnel would benefit from a HH approach, especially in the care and management of patients of explosive injuries.

ABSTRACT 834

Background and aims: The use of intraosseous (IO) needles as an access for resuscitation in pediatric advance life support has led to more pediatric patients being transported with IO needles in place. It would be reasonable to expect that the disposition of these patients would be admission to the intensive care unit, but to date there have been no studies to support this supposition. Aims: To determine the characteristics and disposition of children following IO needle placement referred for transport from an outlying facility. Methods: A retrospective review of the transport database from 1993–2009 of pediatric patients who had an IO as a part of their care. The IRB waived the need for consent. Results: 143 children were transported to a level 1 trauma tertiary care children’s hospital from 25 referral facilities. Patients were 65% male and 35% female with a mean age of 1.20 years (range 0.01–13 years). All had IO’s placed placed by pre-hospital providers, the referral facility, or the transport team. Of the 143 patients transported, 53% were placed for no intravenous access and 34% were placed for no perfusing rhythm. Most common reason for admission to the hospital was combined system failure with 79% of patients admitted to the pediatric intensive care. Of those hospitalized, 58% were discharged home. Conclusions: IO placement is a life-saving measure with most IOs placed by referring facilities prior to transport and few reported complications.

ABSTRACT 35

Background and aims: High childhood mortality rates exist in Myanmar and morbidity is multifactorial. Prior studies show preparedness to manage emergencies is key factor. Effective protocols are not universally used. Educational interventions in this setting must consider: local epidemiology, infrastructure, equipment and personnel availability, provider knowledge and skills, and educational systems. Resuscitation competency is not achieved through didactics but simulation has been shown to improve skill performance. Aims: Proximal study aim was to perform needs assessment for dissemination of simulation curricula based on Helping Babies Breathe platform and American Heart Association PALS protocols throughout Myanmar, with adaptations for local epidemiology and resource availability. Ultimate aim of project is to decrease neonatal and under five mortality rates throughout Myanmar. Methods: A written survey of Burmese physicians was conducted after approval by Johns Hopkins IRB. Participants voluntarily completed surveys during resuscitation courses conducted in Myanmar April 2012. Practicing physicians from private (N= 54) and university affiliated (N= 84) sectors (Total N= 138) completed surveys. Results: Only 58% of physicians surveyed had formal training in pediatric resuscitation. Despite this, 61% previously performed chest compressions on children and 57% manual ventilation. 27% of respondents admitted they had occasion when pediatric CPR was indicated, but didn’t know how to perform it. Only 63% had defibrillators available in hospital and 24% had intra-osseous needles available. Conclusions: Serious training deficits exist in Myanmar for providers responsible for children. There are barriers to providing treatment, including equipment availability. Future directions will focus on designing sustainable programs and implementing dissemination in rural areas.

Effects of Intraosseous and Intravenous Administration of Hextend(r) on Time of Administration and Hemodynamics in a Swine Model

The military recommends that a 500 mL bolus of Hextend® be administered via an intravenous (IV) 18-gauge needle or via an intraosseous (IO) needle for patients in hypovolemic shock.The purposes of this study were to compare the time of administration of Hextend and the hemodynamics of IV and IO routes in a Class II hemorrhage swine model.This was an experimental study using 27 swine. After 30% of their blood volume was exsanguinated, 500 mL of Hextend was administered IV or IO, but not to the control group. Hemodynamic data were collected every 2 minutes until administration was complete.Time for administration was not significant (p=.78). No significant differences existed between the IO and IV groups relative to hemodynamics (p>.05), but both were significantly different than the control group (p<.05).The IO route is an effective method of administering Hextend.