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Three Part Question

In [patients requiring intraosseous access] is [the manual intraosseous infusion device or the semi-automatic intraosseous infusion device] better at [achieving intraosseous access in the prehospital setting]?

Clinical Scenario

Gaining vascular access in the prehospital environment is often challenging. In the circumstance where an intravenous (IV) insertion is delayed or unobtainable, intraosseous (IO) insertion should be attempted. The manual intraosseous infusion device and the semi-automatic intraosseous infusion device are both available, so you question which device offers the best rate of success, accuracy and user satisfaction in the prehospital setting.

Search Strategy

Medline (EBSCO) was searched from 1950 to the end of May 2010, CINAHL (Ovid SP) from 1982 to the end of May 2010 and EMBASE (EMBASE/Elsevier) from 1980 to the end of May 2010 using an established prehospital filter. The references of relevant articles were also reviewed.
Medline was searched using the following strategy: (Emergency medical service$.sh OR emergency medical technic$.sh OR ambulance$.sh OR air ambulance$.sh OR military medicine.sh OR emergency treatment.sh OR emergency medicine.sh OR first aid.sh) AND (pre-hospital.ti OR pre-hospital.tw OR prehospital.ti OR prehospital.tw OR out of hospital.tw OR out-of-hospital.tw OR (ambulance$ or air ambulance$).tw OR paramedic$.ti,tw) AND (infusion.tw OR intraosseous.tw OR IO.tw OR vascular access.tw OR bone injection.tw OR devices.tw) LIMIT to (Humans AND English).

CINAHL was searched using the following strategy: (Emergency medical service$.sh OR emergency medical technic$.sh OR ambulance$.sh OR military medicine.sh OR emergency medicine.sh OR emergency care.sh OR emergency patients.sh OR prehospital care.sh OR transportation of patients.sh OR first aid.sh OR mass casualty incident.sh) AND (pre-hospital.ti OR pre-hospital.tw OR prehospital.ti OR prehospital.tw OR out of hospital.tw OR out-of-hospital.tw OR (ambulance$ or air ambulance$).tw OR paramedic$.ti,tw) AND (infusion.tw OR intraosseous.tw OR IO.tw OR vascular access.tw OR bone injection.tw OR devices.tw) LIMIT to (Humans AND English).

EMBASE was searched using the following strategy: (Ambulance*:de OR ‘prehospital care’:de OR 'emergency health service':de OR ‘paramedical personnel’:de OR ‘military medicine':de OR ‘first aid':de OR ‘emergency medicine':de OR ‘emergency treatment':de OR ‘air ambulance':de OR prehospital:de OR paramedic*:ti,ab OR ambulance*: ti,ab OR ‘out-of-hospital':ti,ab OR ‘out of hospital':ti,ab OR ems:ti,ab OR emt:ti,ab OR ‘emergency services':ti,ab OR ‘emergency medical services':ti,ab OR ‘emergency technicians':ti,ab OR ‘emergency practitioner':ti,ab OR ‘emergency dispatch':ti,ab OR ‘emergency despatch':ti,ab OR ‘first responder':ti,ab OR ‘emergency rescue':ti,ab OR ‘emergency resus':ti,ab) AND (‘infusion’:ti,ab OR ‘intraosseous’:ti,ab OR ‘IO’:ti,ab OR ‘vascular access’:ti,ab OR ‘bone injection’:ti,ab OR ‘devices’:ti,ab) LIMIT to (Humans AND English).

Search Outcome

A total of 2100 articles were located in the three databases, of which two were suitable for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hartholt et al, 2010, The Netherlands	65 adults (>14 years old; Jamshidi 15G, BIG 15G or FAST1) and 22 paediatric patients (Jamshidi 15G or BIG 18G)	Randomised controlled trial, single-blinded prospective	Insertion times, success rates, complication rates and user satisfaction were assessed.	The Jamshidi needle was significant quicker to insert than the FAST1 (p=0.002). Success rate, complications and user satisfaction showed no difference. Although not reaching statistical significance (p>0.05), the Jamshidi needle had a higher first time success rate and a lower adverse event rate.	No follow up
Frascone et al, 2007, USA	89 in 1st field trial (FAST1), 89 in 2nd field trial (EZ-IO)	Prospective pilot study	Success rates and provider comfort were assessed. The insertion times were retrospectively gathered via telephone interviews relying on estimations from the operator. Insertion failures, removal of needle issues and attempts were also recorded, but showed no statistical significance.	Success rates: FAST1 72% versus EZ-IO 87% (p=0.009). There was no statistically significant difference (p=0.510, p=0.493) in success rates between first attempt or multiple attempt providers. Similar user satisfaction. EZ-IO reported to be quicker.	No power calculation was undertaken. Non-randomisation, potential for learning effect, self-reported data. 44% vs 18% using FAST1 vs EZ-IO had at least one prior insertion. The decision to compare the devices was made in retrospect.

Comment(s)

These studies were relatively small and only one was blinded. In the blinded study by Hartholt et al, the manual intraosseous device (Jamshidi) demonstrated better success rates and faster insertion rates compared with the semi-automatic device (BIG). In the unblinded study by Frascone et al, the semi-automatic intraosseous device (EZ-IO) produced better success rates compared with the FAST 1 manual device, although this may be unsurprising given the approach used in this study. Thus, from a clinical perspective, further randomised clinical trials are required to determine the best intraosseous device for the prehospital sector.

Clinical Bottom Line

Traditional manual intraosseous infusion devices have better success rates and faster insertion times compared with semi-automatic intraosseous infusion devices in the prehospital setting.

References

1. Burgess S. The development of an updated prehospital search filter for the Cochrane Library: Prehospital Search Filter Version 2.0. Emerg Primary Health Care 2010:8.
2. Hartholt KA, van Lieshout EM, Thies WC, et al. Intraosseous devices: a randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care 2010;14:6–13.
3. Frascone RJ, Jensen JP, Kaye K, et al. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care 2007;11:164–71.