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Procedural Skills (SLO6)
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A pre-alert call arrives for a 21 year old male patient involved in a road traffic collision with extensive blood loss. The paramedics have been unable to establish intravenous access in his upper limbs. The nurse is unable to record a blood pressure. Which of the following sites would be your priority to establish access?
Answer:
Intraosseous (IO) access is an effective route for fluid resuscitation, drug delivery and laboratory evaluation that may be attained in all age groups and has an acceptable safety profile. IO access is a recommended technique for circulatory access in resuscitation of critically ill patients and in cardiac arrest. IO access should be established if vascular access is not rapidly achieved (if peripheral IV access is poor, inaccessible or delayed.)Intraosseous Access
Procedural Skills (SLO6)
Last Updated: 26th January 2023
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
- Humeral insertion
- 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 |
