Intraosseous Placement Research Articles

Evaluating the Success Rate of Distal Femur Intraosseous Access Attempts in Pediatric Patients in the Prehospital Setting: A Retrospective Analysis

Objectives Although the proximal tibia is a common site for intraosseous (IO) line placement in pediatric patients, previously published data indicate high malposition rates in infants and children at this location. Although distal femur IO lines generally demonstrate higher flow rates than those at the proximal tibia, to date, there have been no published studies assessing distal femur IO access in pediatric patients. Thus, we aimed to compare the success rates of pediatric IO line insertion attempts between the proximal tibia and the distal femur in a prehospital setting. Methods We conducted a retrospective chart review of prehospital pediatric patients who underwent at least one IO line placement attempt by Palm Beach County Fire Rescue from May 2015 to January 2024. We excluded records lacking specific documentation of IO attempt location. We compared the unadjusted success rates of distal femur to proximal tibia, and we also compared success rates after propensity score matching and multivariable logistic regression. Secondarily, we assessed the prehospital complication rate of the IO lines at each anatomical site. Results We identified 163 pediatric patients who had an IO attempt and were eligible for analysis. Median age was 1.9 years (IQR: 0.46 to 4.2 years). Among those 163 patients, there were 234 vascular access attempts, including 82 IO attempts at the distal femur and 72 at the proximal tibia. The unadjusted success rate of distal femur attempts was 89.0%, compared to 84.7% for proximal tibia attempts, a difference of 4.3% (95% CI −6.4 to 15.0%). After propensity score matching, we found an adjusted odds ratio of 2.0 (95% CI 0.66 to 6.8), favoring the distal femur for successful placement. Prehospital complication rates were similar for distal femur (5.5%) and proximal tibia (4.9%). Conclusions This retrospective analysis of pediatric patients in a prehospital setting suggests that IO line placement at the distal femur might offer a marginally higher success rate compared to the proximal tibia. Despite not reaching statistical significance, these findings support the consideration of distal femur as a viable option for IO placement in the pediatric population.

Insertion sites of iliosacral screws on the posterior ilium: Implications for posterior pelvic fixation

ObjectivesLateral compression type II pelvic ring injuries can be treated with fixation through open or percutaneous approaches depending on the injury pattern and available osseous fixation pathways. The start site of iliosacral screws to stabilize these injuries should be on the unstable posterior iliac fragment; however, our understanding of start sites for iliosacral screws has not been developed. The purpose of this study is to provide an analysis of iliosacral screw start sites on the posterior ilium to help guide treatment of pelvic ring injuries. MethodsOne-hundred and seventeen consecutive patients at an academic level I trauma center with pelvic ring injuries who underwent surgical treatment with iliosacral screws were included in the final analysis. The start sites of iliosacral screws with confirmed intraosseous placement on a postoperative computed tomography were mapped on the posterior ilium and analyzed according to the sacral segment and type of iliosacral screw. ResultsOne-hundred and seventeen patients were included in the final analysis. Of the total of 272 iliosacral screw insertion sites analyzed, 145 (53%) were sacroiliac-style screws and 127 (47%) were transsacral screws. The insertion sites for sacroiliac-style screws and transsacral screws at different sacral segment levels can vary but have predictable regions on the posterior ilium relative to reliable osseous landmarks. ConclusionsIliosacral screws start sites on the posterior ilium have reliable regions that can be used to plan posterior fixation of pelvic ring injuries.

Improving pediatric procedural skills and EPA assessments through an acute care procedural skills curriculum.

Acute procedural skill competence is expected by the end of pediatric residency training; however, the extent to which residents are actually competent is not clear. Therefore, a cross-sectional observational study was performed to examine the competency of pediatric residents in acute care procedures in emergency medicine. Pediatric residents underwent didactic/hands-on "Acute Procedure Day" where they performed procedures with direct supervision and received entrustable professional activity (EPA) assessments (scores from 1-5) for each attempt. Procedures included: bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR) with defibrillation. Demographic information, perceived comfort level, and EPA data were collected. Descriptive statistics and Pearson correlation for postgraduate year (PGY) versus EPA scores were performed. Thirty-six residents participated (24 PGY 1-2, and 12 PGY 3-4). Self-reported prior clinical exposure was lowest for chest tube placement (n = 3, 8.3%), followed by IOs (n = 19, 52.8%). During the sessions, residents showed the highest levels of first attempt proficiency with IO placement (EPA 4-5 in 28 residents/33 who participated) and BVM (EPA 4-5 in 27/33), and the lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). There was a strong correlation between PGY level and EPA score for intubation, but not for other skills. Entrustability in acute care skills is not achieved with current pediatrics training. Research is needed to explore learning curves for skill acquisition and their relative importance.

81 A Snapshot of Entrustability of Acute Care Procedural Skills in Paediatrics Residents

Abstract Background General paediatricians are expected to be competent in the resuscitation of children and important to this competency is the ability to perform certain acute care procedural skills. Paediatric residents are expected to be competent in these procedural skills by the end of their training as specified by the Royal College (RCPSC). However, the extent to which residents are actually competent is not fully assessed or understood. There are currently no evidence-supported guidelines suggesting the best path toward procedural skills competency for residents, and they are less likely to receive formal training and or supervision for completing procedural skills than their nursing counterparts. They also report feeling inadequately prepared. To address this gap, the Paediatrics program at McMaster University aimed to conduct a longitudinal cross-sectional study examining the competency of their trainees in specific acute care procedures. Objectives The purpose of this first study was to present a cross-sectional observation of the entrustability of paediatric residents in 6 procedural skills. Design/Methods The procedures were bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR), and defibrillation, which are all requirements of the RCPSC. Paediatric residents attended an “Acute Care Procedure Day” where they performed each procedure with direct observation and feedback. Entrustable professional activity (EPA) scores (from 1 to 5) were recorded for each attempt. Prior, a 1-hour interactive lecture was given that included procedural information and a video demonstration of each procedure. Residents received a copy of the milestones per EPA. Demographic information, self-perceived comfort, and EPA data were collected. Descriptive statistics and Pearson correlation for PGY level versus EPA scores were performed. Results Of the 36 residents who participated, 24(67%) were in postgraduate year (PGY) 1-2, and 12 PGY 3-4(33%). Reported levels of past experience were lowest for placement of chest tubes (n=3, 8.3%), followed by IOs (n=19, 52.8%). During the sessions, residents showed the highest levels of initial entrustment with IO placement (EPA 4-5 in 28/33), BVM skills (EPA 4-5 in 27/33), and CPR (EPA 4-5 in 16/25), and lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). Despite this, self-reported overall confidence after training for these procedures was moderate to high. There was strong correlation between PGY level and EPA score for intubation, and no correlation for the other procedures. Conclusion Our findings show that entrustability of certain acute care skills is not being obtained (i.e., defibrillation, chest tube placement), and that there were large discrepancies between entrustment scores and perceived comfort among the PGY levels. Further research is needed to characterize the learning curves for these skills, and their relative importance in paediatrics training.

A Quest for Better Strategy in Pediatric Intraosseous Placement Using Radiographic Measurements in Patients Younger Than 2 Years.

Intraosseous (IO) needles are used to obtain vascular access in pediatric patients during emergent situations. Recent literature has raised concern about high rates of IO malposition in younger children. Despite the widespread use of IO access in the pediatric population, there is scarce evidence regarding the ideal needle length or optimal access site. This study uses a radiographic approach to determine the appropriate IO needle length and access site to minimize the risk of malposition in children younger than 2 years. Radiographs of the lower extremities were obtained from the electronic database from a single tertiary care center. Using lateral views, anteroposterior measurements were obtained at 2 axial planes, located 1 cm superior to distal femur physis and 1 cm inferior to distal tibia physis. Based on the measurements, we calculated the probable needle tip positions if the needle was placed to the hub at the skin level using the EZ-IO (Teleflex Ltd, Wayne, PA) preset needle sizes. For subjects younger than 6 months, the 25-mm needle minimized malposition in the femur site with a 45.7% appropriate position rate, and the 15-mm needle minimized malposition in the tibia site with a 57.1% appropriate position rate. For the older age groups, we did not find a standard needle that would consistently minimize malposition in the femur site. For the tibia site, the 25-mm needle minimized malposition risk, with appropriate position rates of 81.0%, 87.5%, and 91.1% in the 6- to 12-month, 13- to 18-month, and 19- to 24-month groups, respectively.

From Private Practice to Academia: The Experience of a General Academic Pediatrician.

After pediatric residency, the author worked in a rural community where he was able to immediately practice skills acquired during training such as intubations, bag-mask ventilation, IV placement, ear irrigation, foreign body removal from eyes and ears, abscess incision and drainage, intraosseous placement for rapid hydration of a severely dehydrated infant, EKG, X-ray readings, and ear-irrigations to cite but a few examples. Furthermore, the writer acquired other high-valued procedural skills such as neonatal male circumcision, frenotomy, ligation of supernumerary digits, and manual separation of labial adhesions. The author feels that he could only have acquired and maintained these skills by working in a busy rural pediatric practice. When the writer later became a faculty member, he was able to effectively train medical students and pediatric residents to acquire these same skills. Even though there is a paucity of research information on procedural skills acquisition among general pediatric residents, the writer proposes that the recruitment of full-time general academic pediatricians with real-world experience may be potentially beneficial for the training of medical students and pediatric residents.

Current utilization of interosseous access in pediatrics: a population-based analysis using an EHR database, TriNetX

BackgroundWhen central or peripheral intravenous access cannot be achieved in a timely manner, intraosseous (IO) access is recommended as a safe and equally effective alternative for pediatric resuscitation. IO usage and its complications in the pediatric population have been primarily studied in the setting of cardiac arrest. However, population-based studies identifying noncardiac indications and complications associated with different age groups are sparse.ResultsThis was a retrospective observational cohort study utilizing the TriNetX® electronic health record data. Thirty-seven hospitals were included in the data set with 1012 patients where an IO procedure code was reported in the emergency department or inpatient setting. The cohort was split into two groups, pediatric subjects < 1 year of age and those ≥ 1 year of age. A total incidence of IO line placement of 18 per 100,000 pediatric encounters was reported. Total mortality was 31.8%, with a higher rate of mortality seen in subjects < 1 year of age (39.2% vs 29.0%; p = 0.0028). A diagnosis of cardiac arrest was more frequent in subjects < 1 year of age (51.5% vs 38.0%; p = 0.002), and a diagnosis of convulsions was more frequent in those ≥ 1 of age (28.0% vs 13.8%; p <0.01). Overall, 29 (2.9%) subjects had at least one complication.ConclusionsMore IOs were placed in subjects ≥ 1 year of age, and a higher rate of mortality was seen in subjects < 1 year of age. Lower frequencies of noncardiac diagnoses at the time of IO placement were found in both groups, highlighting IO may be underutilized in noncardiac settings such as convulsions, shock, and respiratory failure. Given the low rate of complications seen in both groups of our study, IO use should be considered early on for urgent vascular access, especially for children less than 1 year of age.

Validation of a 3-Dimensional-Printed Infant Tibia for Intraosseous Needle Insertion Training.

Current bone models used for pediatric intraosseous (IO) placement training are expensive or lack anatomic and/or functional fidelity. This technical report describes the development and validation of a 3-dimensional printed (3DP) tibia from a pediatric lower extremity computed tomography scan for IO procedural training. Multiple 3DP tibia models were printed using a dual-extrusion fused-filament fabrication printer. Models underwent iterative optimization until 2 final models, one of polypropylene (3DP clear) and the other of polylactic acid/polypropylene (3DP white), were selected. Using an exploratory sequential mixed-methods design, a novel IO bone model assessment tool was generated. Physicians then used the assessment tool to evaluate and compare common IO bone models to the novel 3DP models during IO needle insertion. Thirty physicians evaluated the provided pediatric IO bone models. Compared with a chicken bone as a reference, the 3DP white bone had statistically significantly higher mean scores of anatomy, heft, sense of being anchored in the bone, quality of bone resistance, and "give" when interfaced with an IO needle. Twenty-two of the 30 participants ranked the 3DP white bone as either 1st or 2nd in terms of ranked preference of pediatric IO bone model. A 3DP white bone costs $1.10 to make. The 3DP IO tibia models created from real-life computed tomography images have high degrees of anatomic and functional realism. These IO training models are easily replicable, highly appraised, and can be printed at a fraction of the cost of commercially available plastic models.

Is the Use of Intraoperative 3D Navigation for Thoracolumbar Spine Surgery a Risk Factor for Post-Operative Infection?

Pedicle screw fixation is a technique used to provide rigid fixation in thoracolumbar spine surgery. Safe intraosseous placement of pedicle screws is necessary to provide optimal fixation as well as to avoid damage to adjacent anatomic structures. Despite the wide variety of techniques available, none thus far has been able to fully eliminate the risk of malpositioned screws. Intraoperative 3-dimensional navigation (I3DN) was developed to improve accuracy in the placement of pedicle screws. To our knowledge, no previous studies have investigated whether infection rates are higher with I3DN. A single-institution, retrospective study of patients age > 18 undergoing thoracolumbar fusion and instrumentation was carried out and use of I3DN was recorded. The I3DN group had a significantly greater rate of return to the operating room for culture-positive incision and drainage (17 (4.1%) vs. 1 (0.6%), p = 0.025). In multivariate analysis, the use of I3DM did not reach significance with an OR of 6.49 (0.84–50.02, p = 0.073). Post-operative infections are multifactorial and potential infection risks associated with I3DN need to be weighed against the safety benefits of improved accuracy of pedicle screw positioning.

Location Matters in Syndesmosis Screw Breakage: Interosseous Breakage and Breakage Location Within the Tibia Affect Rates of Removal Secondary to Pain

Category:Ankle; Ankle; TraumaIntroduction/Purpose:Broken or loose syndesmotic screws are typically reported to be clinically asymptomatic, however, screw breakage can lead to significant pain depending on location. Syndesmosis screws that span the incisura are particularly at an increased risk for painful outcomes. In patients with intraosseous screw breakage, normal physiologic translation where the distal convex of the fibula fits into the concave tibial incisure can lead to painful bony erosion overtime. The purpose of this investigation is to assess variables that my predict location of syndesmosis screw breakage and to also assess the effect of screw breakage location on eventual removal secondary to pain.Methods:A retrospective analysis of 1,056 patients who underwent syndesmosis fixation revealed 88 patients (121 screws) who experienced pst-operative syndesmosis screw breakage and met predetermined inclusion criteria. Patient demographic data, BMI, comorbidities, pain scores, complication rate, and revision rate were all collected. Screw length, width, number, placement height above the tibial plafond, angle, location of breakage, breakage distance location on the screw and implant removal secondary to pain were also collected. A series of binomial logistic regressions were performed to ascertain the effects of the collected variables on the likelihood of breakage location and removal secondary to pain. Regression analysis included intraosseous versus clear space breakage, tibia versus fibula breakage, and removal secondary to pain in each breakage location group (tibia, fibula, clear space).Results:Of the 121 broken screws, 91 (75.2%) broke within an intraosseous (IO) location (68 patients, 77.3%). Twenty-eight screws (23%.1) (18 patients, 20.5%) broke exclusively within the clear space (CS). Sixty screws (52 patients, 59.9%), had IO breakage within the tibia, while 29 screws (24 patients 27.7%) had breakage within the fibula. Two screws (2 patients, 2.27%) occurred within an intraosseous location and the clear space. Intraosseous screw breakage was associated with higher risk removal secondary to pain (P=.020). Multiple screw usage associated with an increased risk for CS breakage (P =.012). IO and CS screw angle and placement had no effect on screw breakage location (P =.629, P =.570). Screw breakage closer to the CS (P=.001), increased number of screws used (P=.003), and higher patient pain scores (P =.003) were associated increased risk of removal due to pain within the IO tibia breakage group.Conclusion:Syndesmotic screw breakage location plays a more important role than previously reported. When compared to clear space, intraosseous breakage is associated with increased rates of removal due to pain. Breakage location within the tibia occurring closer to the clear space is associated with higher rates of removal secondary to pain and higher patient report pain scores. Usage of multiple screws was found to be the only significant predictor of clear space vs intraosseous breakage; all other variables were found to be non-contributary, including no appreciated significance of screw placement in relation to the tibial plafond or screw angle.

Pre-hospital intraosseous use in children: Indications and success rate.

Intraosseous (IO) needle insertion is an effective method to obtain circulatory access in unwell children. We conducted a 12-month retrospective record review of children aged less than 18 years who had a recorded IO attempt by Ambulance Victoria paramedics. Sixty-five children underwent IO attempt during pre-hospital care, 60 had IO outcome recorded and were included. 58/60 (96.7%) children had IO successfully placed, 35 were aged <5 years. Cardiorespiratory arrest (39/58, 67.2%) and status epilepticus (11/58, 19%) were the most common indications. While IO placement is uncommonly performed pre-hospital, in critical situations there is a high success rate.

43 The Importance of Intraosseous Placement Location on Infusion Rates and Infusion Pressures in a High Bone Density Humerus and Sternum Cadaveric Swine (Sus Scrofa) Model

Intraosseous (IO) access is an emergent bridge to central venous access for the critically ill and injured. To effectively infuse fluids or blood products intraosseously, infusion flow rates must be sufficient to sustain life but at pressures that are low enough to avoid complications. However, published reports indicate that up to 30% of landmark-based IO catheter placements are suboptimal, which can result in low infusion flow rates at elevated infusion pressures. What was needed was a randomized prospective cadaveric study to determine infusion flow rates, mean pressures, and peak pressures based on IO catheter tip placements.

Procedural Competency in Academic Emergency Medicine Attending Physicians: How Is Competency Maintained and Evaluated by Academic Institutions in the US?

IntroductionThere have been numerous studies examining the minimum graduation requirements for resident training of procedural skills within Emergency Medicine programs; however, how academic medical centers in the United States maintain Emergency Medicine attending procedural skill competency has not been explored.ObjectivesThe aim of this study was to examine the processes in place to evaluate and track the procedural skills practices of Emergency Medicine attending physicians at academic institutions in the US.MethodsAn exploratory cross-sectional survey was sent to all 39 ACGME-accredited Emergency Medicine programs in the US through a REDCap survey in 2020. Survey items inquired about the current methods in place to maintain competence on 13 procedural skills performed by Emergency Medicine providers.ResultsThe survey response rate was 26.9%. The majority of programs did not have a process in place to evaluate procedural skills at the time of initial appointment (74.3%), and almost half of participating programs reported no formalized process during employment (51.3%). Institutions reported no minimum required number for the following procedures: dislocation reduction, intraosseous placement, lateral canthotomy, lumbar puncture, paracentesis, pericardiocentesis, thoracentesis, transvenous cardiac pacing, and tube thoracostomy. For central venous access, cricothyrotomy, endotracheal intubation, and procedural sedation, 25.6% or less of institutions had minimum annual requirements.ConclusionThis study summarized the current methods in place to assess Emergency Medicine attending procedural skills at US academic institutions and demonstrated that the majority of programs lack a formalized method to assess attending procedural competency. Further research is needed to determine the value and benefit of different methods available for procedural skill competency assessment. It is believed that preventing procedural skill decay in attending physicians by a standardized process has the potential to improve patient outcomes, reduce costs and complication rates, and improve physician self-esteem, well-being, and confidence.

Sternal Intraosseous Devices: Review of the Literature.

IntroductionThe intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased.MethodsThe authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review.ResultsSternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR.ConclusionThe sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.

Intraosseous vascular access using the EZ-IO can be safely maintained in the adult proximal humerus and proximal tibia for up to 48 h: Report of a clinical study.

Historically, intraosseous (IO) vascular access devices cleared to market by the US FDA have been restricted to 24-h use. An observational study was conducted to determine the safety of IO access for a period up to 48 h in adult volunteers. A 2-arm randomized, stratified, parallel assignment, prospective interventional study was conducted at ICON Early Phase Services in San Antonio, Texas, United States. Study subjects were adult volunteers who were healthy or with a history of mild to moderate renal disease and/or controlled diabetes. Subjects were randomized to receive IO access (Arrow EZ-IO Vascular Access System, Teleflex Medical Incorporated, Morrisville, NC, USA) in the proximal humerus or the proximal tibia and maintain the indwelling catheter for 48 h. Subjects were monitored for the entire dwell time. A culture specimen was drawn from the indwelling catheter tip before removal and insertion site x-rays were taken. 121 subjects were randomized: 79 healthy, 39 with diabetes, and three with diabetes and renal insufficiency. The mean catheter dwell time was 48.0 ± 0.2 h. Overall first attempt success rate was 98.4%. Infusion pain was the most commonly reported adverse event. There were no serious complications or unanticipated adverse events. This is the first known study examining the safety of IO access over a 48-h dwell time. The study corroborates the literature findings, demonstrates device safety, and provides evidence supporting the extended indication for a dwell time to 48 h in adult patients. IO placement and infusion best practices/guidelines were confirmed or established.

Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access.

Peripheral intravenous placement in children can be challenging. Different techniques have been used to improve first pass success rates in children with known history of difficult venous access including surface landmarking, local warming, transillumination, ultrasonography, epidermal nitroglycerin, central venous access, intraosseous placement, and venous cutdown. Among these, ultrasound guidance has garnered the most interest among anesthesiologists. The cumulative literature surrounding the utility of ultrasound-guided peripheral intravenous placement in children with and without difficult venous access has shown mixed results. Literature on the utility of ultrasound guidance for peripheral intravenous placement in children under deep sedation or anesthesia is limited but encouraging. This review summarizes the overall evidence for ultrasound-guided peripheral intravenous placement in children with difficult venous access under deep sedation or general anesthesia. Furthermore, five subtly varying approaches to ultrasound-guided peripheral intravenous placement with their advantages and disadvantages will be discussed. One of these five approaches is Dynamic Needle Tip Positioning. Utilizing a short axis out of plane ultrasound view, this promising technique allows for accurate needle tip localization and may increase the success rate of peripheral intravenous placement, even in small children, under deep sedation, or general anesthesia.

Extravasation from a Misplaced Intraosseous Catheter.

A 75-year old female presented in cardiac arrest with a right tibial intraosseous (IO) catheter through which prehospital medications were administered. The catheter, which had been placed by emergency medical services, was noted in the emergency department to be misplaced and was removed. Due to extravasation of the medications, the patient suffered localized tissue necrosis and eventually required skin grafting. This case illustrates the importance of confirming appropriate IO placement.

Pediatric Prehospital Intraosseous Access During Combat Operations in Iraq and Afghanistan.

Vascular access in critically ill pediatric patients can be challenging with delays potentially leading to worse outcomes. Intraosseous (IO) access has a low rate of complications and can be utilized to administer lifesaving medications. Combat medics are trained to treat adults but may also be required to treat children in the deployed setting. Vascular access in children can be challenging, especially in a hypovolemic state. There are limited data on prehospital lifesaving interventions in children in the combat setting. We sought to characterize the use of IO access in pediatric patients who sustained trauma in the combat setting. We queried the Department of Defense Trauma Registry for all pediatric patients admitted to fixed-facilities and forward surgical teams in Iraq and Afghanistan from January 2007 to January 2016. Within that population, we searched for all subjects with a documented prehospital IO or intravenous (IV) access obtained. Subjects with both an IO and IV documented were placed into the IO category. We separated subjects by age groupings: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. During the study period, there were 3439 subjects 17 years or younger. There were 177 in the IO cohort and 803 in the IV cohort. Most subjects in the IO cohort were in the 10- to 14-year-old age group (35.6%), male (79.1%), located in Afghanistan (95.5%), and injured by explosive (52.0%), with lower survival rates than the IV cohort (68.9% vs 90.7%, P < 0.001). Hemostatic dressing application, tourniquet application, intubation, cardiopulmonary resuscitation, sedative administration, ketamine administration, and paralytic administration were all higher in the IO cohort. Pediatric IO placement in the prehospital setting occurred infrequently. Pediatric subjects receiving an IO had higher injury severity scores and higher mortality rates compared with those who received an IV only. Intraosseous use appears to be used more often in critically ill pediatric subjects.

Tissue response to porous high density polyethylene as a three-dimensional scaffold for bone tissue engineering: An experimental study

High density polyethylene (HDPE) is a synthetic biomaterial used as a three-dimensional scaffold for bone defect reconstruction. Reports differ with regard to its biological response, particularly its osteoconductive capacity. The aim of the present work was to histologically and histomorphometrically evaluate tissue response to porous HDPE. An in vivo study was conducted in rat tibia to evaluate osteogenic capacity, angiogenesis, inflammatory response, and the presence of multinucleated giant cells 14 and 60 days post-biomaterial implantation. Histological examination 14 days post-implantation showed fibrovascular tissue inside pores and on the surface of porous HDPE, acute inflammatory response, scant multinucleated giant cells (MNGCs), and lamellar bone in contact with the biomaterial. An increase in the proportion of lamellar bone tissue, no inflammatory response, and a decrease in the number of MNGCs were observed at 60 days. The histomorphometric study showed a significant time-dependent increase both in the area of bone tissue formed in contact with the porous HDPE (14d: 24.450 ± 11.623 µm2 vs. 60d: 77.104 ± 26.217 µm2, p < 0.05) and in the percentage of bone tissue in contact with the porous HDPE (osseointegration). A significant decrease in the number of MNGCs was also observed at 60 days post-implantation. Porous HDPE showed adequate osteoconductive properties, and only caused an initial inflammatory response. Although this biomaterial has traditionally been used juxtaosseoulsy, its adequate osteoconductive properties broaden the scope of its application to include intraosseous placement.

The Prehospital Trauma Registry Experience With Intraosseous Access.

Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only. We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group. Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05). Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.