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Questions Answered: 127

Final Score 99%

126
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Procedural Skills (SLO6)

Question 68 of 127

A 10 year old boy is brought into ED following a collapse. He has no signs of life and paramedics have started CPR. They have not yet managed to establish intravenous access. Your consultant asks you to perform intraosseous access at the proximal tibia. Which of the following is the most appropriate landmark?

Answer:

The insertion site is the anteromedial surface of the proximal tibia, approximately 2-3 cm below the tibial tuberosity.

Intraosseous Access

If intravenous (IV) access is difficult or impossible, consider the intraosseous (IO) route. IO injection of drugs achieves adequate plasma concentrations in a time comparable with injection through a vein.

APLS guidelines recommend that intraosseous access is indicated if other attempts at venous access fail or if they will take longer than 1 minute to carry out. IO is also the recommended technique for circulatory access in cardiac arrest in children.

Site

The three main insertion sites for IO access recommended for use in adults are the proximal humerus, proximal tibia and distal tibia.

APLS guidelines suggest that the proximal tibia or distal femur are the preferred sites in paediatric patients.

Contraindications

  • Trauma at target site
  • Infection at target site
  • Prosthesis at target site
  • Recent IO access (prev 48 h) in same limb (incl. failed access)
  • Failure to identify anatomical landmarks

Procedure

  • Training in the specific device to be used in clinical practice is essential. Site of insertion, identification of landmarks and technique for insertion will differ depending on the device being used:
    • Humeral insertion
      • The insertion site is the lateral surface of the proximal humerus, at the most prominent aspect of the greater tubercle (about 1 cm above the surgical neck)
    • Proximal tibial insertion
      • The insertion site is the anterior surface of the proximal tibia, 2-3 cm below the tibial tuberosity
    • Distal tibial insertion
      • The insertion site is the anterior surface of the distal tibia, 3 cm above the most prominent aspect of the medial malleolus
    • Distal femur insertion
      • The insertion site is the anterolateral surface of the distal femur, 3 cm above the lateral condyle
  • Once inserted, confirm correct placement before delivery of drugs or infusion of fluids. Attempt to aspirate from the needle; presence of IO blood indicates correct placement; absence of aspirate does not necessarily imply a failed attempt.
  • Flush the needle to ensure patency and observe for leakage or extravasation. This is best achieved using an extension set with 0.9% saline attached to the hub of the needle before use.
  • Once IO access has been confirmed, resuscitation drugs including adrenaline and amiodarone can be infused. Fluids and blood products can also be delivered but pressure will be needed to achieve reasonable flow rates using either a pressure bag or syringe.
  • Follow the manufacturer's guide both for securing the needle and the maximum length of time it can be left in place.

Complications

  • Extravasation into soft tissues surrounding insertion site
  • Dislodgement of needle
  • Compartment syndrome (secondary to extravasation)
  • Fracture or chipping of bone during insertion
  • Physeal plate injury in children
  • Pain related to infusion of drugs/fluid
  • Fat emboli
  • Local infection
  • Osteomyelitis

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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