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PubMed1986

Pediatric emergency intravenous access. Evaluation of a protocol.

Effectiveness of a protocol for intravenous (IV) access during pediatric resuscitation was prospectively evaluated to determine whether utilization of a specified sequence of measures would reduce IV access time compared with resuscitations deviating from the protocol. The protocol involved rapid sequential attempts at percutaneous femoral vein catheterization, saphenous vein cutdown, and intraosseous infusions if initial percutaneous peripheral IV insertion failed. While no single technique provided completely reliable and rapid IV access, utilization of all techniques per protocol significantly improved IV access time. When initial percutaneous peripheral IV attempts failed, resuscitations in compliance with the protocol achieved IV access more rapidly (median, 4.5 minutes) than those deviating from the protocol (median, 10.0 minutes). Even with incomplete compliance, 66% of resuscitations achieved IV access within the first five minutes. Our experience indicates that IV access during pediatric resuscitation should rarely be delayed beyond the fifth minute if all available IV techniques are used.

Adolescent↗
PubMed2001

Assessment of intracranial pressure volume relationships in childhood: the lumbar infusion test versus intracranial pressure monitoring.

OBJECT: This study was undertaken to compare the results of two tests that are widely used to assess intracranial pressure-volume relationships in children: the lumbar steady state infusion test providing information about the resistance to cerebrospinal fluid (CSF) outflow (Rout), and continuous intracranial pressure (ICP) monitoring. METHODS: The study included 28 children aged 5-91 months, on whom both tests were performed. The median duration between the tests was 1 month. With the child in general narcosis, the lumbar CSF pressure was recorded before and during infusion of artificial CSF, and the Rout was calculated on the basis of the opening (Po) and plateau (Pp) pressures (Rout=Pp-Po/infusion rate). ICP was recorded every 5 s using a computer-based system. CONCLUSIONS: We found no significant correlation between Rout and mean ICP asleep. There were no significant relationships between abnormal mean ICPs during sleep (defined as either 10 or 15 mmHg) and abnormally high Rout values (defined as either 10 or 12 mmHg/ml/min), and no significant relationships between abnormally high Rout values (10 or 12 mmHg ml(-1) min(-1)) and the presence of abnormal ICP elevations (defined as either 20 or 25 mmHg and lasting 5 min). Therefore the calculation of Rout by the infusion test performed on children under general anesthesia gave no reliable prediction of abnormal ICP.

Cerebrospinal Fluid Pressure↗
PubMed1986

Pediatric resuscitation without an intravenous line.

The case of a 3-month-old male infant who was found unresponsive and cyanotic in a crib at home is presented. On arrival in the emergency department the child was receiving basic cardiopulmonary resuscitation (CPR) by a rescue squad and was without vital signs in asystole. The patient achieved a stable rhythm and blood pressure before intravenous access was obtained. Epinephrine and atropine were given via the endotracheal route and sodium bicarbonate through intraosseous infusion.

Atropine↗
PubMed1998

Intravenous access in infants and children.

At times, nothing is more difficult, time consuming or frustrating than obtaining vascular access in the pediatric patient. Today, technologic improvements in catheter design and imaging techniques have significantly facilitated line placement and increased the available options for vascular access. All clinicians involved in the care of pediatric patients should have knowledge of the various methods available for venous access, as well as their relative indications, advantages and disadvantages. This article discusses various sites used for venous access in the pediatric patient, as well as techniques that may be used by the pediatrician and those that require surgical consultation.

Catheterization, Central Venous↗
PubMed1992

Typing and screening of blood from intraosseous access.

STUDY OBJECTIVE: To determine if intramedullary aspirate from intraosseous needle placement can be used as a source for evaluating blood compatibility. DESIGN: A prospective, nonrandomized, crossover study. SETTING/PARTICIPANTS: Patients admitted to the hematology/oncology service undergoing bone marrow aspiration for medical purposes. INTERVENTIONS: Patients had simultaneous samples of bone marrow aspiration from the posterior iliac crest and peripheral venous blood drawn and sent for typing and screening. MEASUREMENTS AND MAIN RESULTS: The paired samples were evaluated for ABO and Rh typing as well as the presence of human leukocyte activity by evaluating the reaction strength between the marrow and venous samples. RESULTS: No differences were seen in the reaction strength between the paired samples in any subjects for ABO and Rh typing (P = .90, yielding beta = .0523). In addition, human leukocyte activity was detected in both the marrow and venous samples in one patient. CONCLUSION: Bone marrow aspirates following intraosseous infusion can be used for accurate and reliable typing and screening of blood.

ABO Blood-Group System↗
PubMedDate not supplied

The perceived importance of paramedic skills and the emphasis they receive during EMS education programs.

OBJECTIVE: The National Standard Curriculum for paramedics is currently being revised. There is little scientific evidence of what does and what does not work in prehospital care, and of whether the National Standard Curriculum prepares paramedics for the field. To provide some basis for the current revisions to the National Standard Curriculum, the authors determined which prehospital skills are perceived by paramedics to be the most important, and whether the emphasis placed on those skills during initial and continuing education programs corresponds with the perceived importance. METHODS: Surveys listing 21 paramedic skills were mailed to the directors of 41 EMS agencies who agreed to participate in the study. The directors distributed the surveys to 1,364 paramedics affiliated with their organizations. The participants were asked to rate the importance of each skill, and the emphasis placed on each skill during their initial and continuing education. Skills were ranked on a scale of 0 to 4, with 0 representing no importance or emphasis, and 4 representing the most possible importance or emphasis. RESULTS: Six-hundred of the 1,364 (44%) surveys were returned. Respondents had a mean of 9.9 +/- 5.6 years of EMS experience, and 5.4 +/- 4.0 years of experience as paramedics. The three skills ranked highest in importance were: 1) endotracheal intubation; 2) defibrillation; and 3) assessment. Importance in prehospital care was ranked equal to or higher than emphasis in both initial and continuing education for all skills except splinting and urinary catheterization, which received higher rankings for emphasis in initial education. Emphasis in initial education equaled or exceeded the emphasis in continuing education for all skills except intraosseous infusion. CONCLUSION: The perceived importance of most prehospital skills is very high, and exceeds the emphasis placed on those skills during both initial and continuing education programs. These findings have implications for medical directors, EMS instructors, and persons involved with the revision of the National Standard Curriculum.

Clinical Competence↗
PubMed1994

Intracompartmental sepsis in burn patients.

An uncommon cause of sepsis in patients with large burns is occult intracompartmental infection. A multi-institution review of 1171 burn admissions identified 5 patients (0.4%) who developed intracompartmental sepsis presenting with fever and purulent drainage or fever, erythema, and swelling on clinical examination. Contributing factors may have included high-volume resuscitation, delayed escharotomy, extravasated intraosseous infusion, cannulation-related arterial injury, and splinting or positioning difficulties. A high index of suspicion and an aggressive surgical approach facilitate successful management of this unusual problem.

Adult↗
PubMed2003

Small-volume fluid resuscitation for the far-forward combat environment: current concepts.

Hemorrhage remains the primary cause of death on the battlefield in conventional warfare. With modern combat operations leading to the likelihood of significant time delays in air evacuation of casualties and long transport times, the immediate goals of the Army's Science and Technology Objectives in Resuscitation are to develop limited- or small-volume fluid resuscitation strategies, including permissive hypotension, for the treatment of severe hemorrhage to improve battlefield survival and prevent early and late deleterious sequelae. As an example, the U.S. Army has invested much effort in the evaluation of hypertonic saline dextran (HSD) as a plasma volume expander, at one tenth to one twelfth the volume of conventional crystalloids, in numerous animal models of hemorrhage. These studies have identified HSD as a potentially useful field resuscitation fluid. In addition, preliminary studies have used HSD under hypotensive resuscitation conditions, and it has been administered through intraosseous infusion devices for vascular access. This research suggests that many of the difficulties and concerns associated with fluid resuscitation for treating significant hemorrhage in the field can be overcome. For the military, such observations have important implications toward the development of optimal fluid resuscitation strategies under austere battlefield conditions for stabilization of the combat casualty.

Dose-Response Relationship, Drug↗
PubMed2006

Antimicrobial regional limb perfusion in horses.

Regional limb perfusion involves administration of an antimicrobial solution into the vasculature of a selected portion of the limb that has been isolated from the systemic circulation by controlled application of a tourniquet. The technique provides high antimicrobial concentrations in the region of interest and greatly contributes to the elimination of infection.

Animals↗
PubMed2000

[Suppression of graft versus host reaction by depositing a magnet-controlled adriamycin dosage form in bone marrow allotransplantation in animal experiments].

The main causes of failures during allogenous bone marrow transplantation is the development of graft versus host reactions. The methods of its prevention and treatment are the use of large doses of human toxic cytostatics and immunosuppressants aimed against donor immunocompetent cells. A way of preventing the adverse effects of cytostatics are targeted transport of long-acting cytostatic dosage forms to an organ or target cell through carriers, such as liposomes, microcapsules, microspheres and their conjugates with monoclonal antibodies. For this purpose, the study used gelatin and gum arabic microspheres containing the immunosuppressive cytostatic adriamycin. To enhance the efficiency of cytostatic depositing at the site of transplantation, the procedure of intraosseous transplantation of allogenous bone marrow transplantation with long-acting adriamycin depositing was developed. With this approach, the authors could not only deposit the agent, but could substantially increase the proportion of donor cells kept at the site of grafting as compared to the intravenous and intraosseous infusion of donor cells. The main advantage of the new technique of allogenous bone marrow transplantation in combination with a long-acting cytostatic dosage form is that acute and chronic graft versus host reactions can be inhibited long by using adriamycin in subtherapeutic dosages.

Animals↗
PubMed1999

Epinephrine-induced potentially lethal arrhythmia during arthroscopic shoulder surgery: a case report.

Arthroscopic shoulder surgery performed on a healthy female could have resulted in a fatal outcome when the epinephrine present in the arthroscopic irrigating solution contributed to the onset of ventricular tachycardia requiring defibrillation during surgery. During this procedure, the shoulder was infiltrated with 30 mL of a 1:100,000 solution of epinephrine into the subacromial space and glenhumeral joint. Subsequently, instrumentation of the glenhumeral joint by the orthopedic surgeon with a standard arthroscopy trocar resulted in a 0.5-cm size lesion to the posterior humeral cortex. Minutes after the start of the surgical procedure, the patient displayed an abrupt onset of ventricular tachycardia and hypertension. These signs and symptoms suggested an intraosseous infusion of both infiltrated and irrigation solution containing epinephrine through the lesion in the humeral cortex. Approximately 800 mL of a .01 mg/mL concentration of irrigation solution containing epinephrine was used. A diagnosis of epinephrine-induced ventricular tachycardia was made. The arthroscopic irrigating solution was immediately discontinued and lidocaine, 100 mg intravenously, was administered; however, the patient's cardiac rhythm degenerated into a sustained ventricular tachycardia that was unresponsive to pharmacologic intervention. A full code was called; the surgeon, anesthesia team, and operating room personnel succesfully provided advanced cardiac life support and cardioverted the patient back into a sinus rhythm with no untoward effects.

Arthroscopes↗
PubMed2000

[Reduced but better health care for armed forces].

The Swedish Armed Forces are presently undergoing the most extensive reorganization and downscaling in their history. In a new set of objectives for the Swedish Armed Forces Medical Service laid down by the Surgeon General, the aim is to provide combat casualty care with a quality on par with that of the civilian, peace-time health care system. This will be achieved by establishing advanced trauma care by specialist physicians and nurses closer to the point of injury, using armoured medical evacuation vehicles, and by introducing new treatment modalities such as intraosseous infusion using hyperoncotic solutions.

Female↗
PubMed1991

Intraosseous administration of digoxin: same-dose comparison with intravenous administration in the dog model.

Intraosseous access has become the method of choice for venous access in critically ill and injured children when more traditional methods are not immediately available. However, there is a paucity of information concerning drug levels achieved via the intraosseous route. We report initial data on the comparison of serum digoxin levels after administration of the drug to dogs through both the intraosseous and intravenous routes. These data indicate that intraosseous infusion of digoxin results in similar serum levels to those attained after IV administration, and may therefore afford a reliable means of initial digitalization.

Animals↗
PubMed1991

Bone marrow as a means of venous drainage for a microvascular osteocutaneous flap.

Intraosseous infusion of fluid had been used in traumatology. Here we describe a clinical situation in which bone marrow is first used for drainage of venous blood in a free osteocutaneous flap. Two factors account for the survival of the large osteocutaneous flap in which venous anastomosis was impossible. (1) In the design of the arterial circuit and the major route of venous drainage, there were two ends of the peroneal artery of the osteocutaneous flap. Both its upper and lower ends were anastomosed to the anterior tibial artery of the recipient site to constitute an uninterrupted arterial circulation. This prevented stagnation of arterial flow and thrombosis of the arterial anastomosis. (2) The major route of venous drainage was through bone marrow. The initial congestion was finally overcome by the development of neovascularization. Bone scan showed good survival of bone with increased uptake of radioactivity. At 3 years follow-up, roentgenogram showed bone union, and the patient had no trouble walking. The continuity of the anterior tibial artery, which had been interrupted by trauma, was restored by this flap.

Accidents, Traffic↗
PubMed1990

[Intra-osseous route. Administration route of drugs in cardiac arrest].

We describe the case of a 6 month-old infant suffering from cardiac arrest and successfully resuscitated after epinephrine had been administered through the intraosseous route. During emergency care, vascular access is critical but may be very difficult in young children. Therefore intraosseous infusion appears to be a very efficient alternative for quick administration of drugs and fluids when vascular access is not easily obtained.

Bone Marrow↗