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Three Part Question

In [patients requiring IO access] is [the Bone Injection Gun better than standard intraosseous needles] at [safely and rapidly acquiring intraosseous access]?

Clinical Scenario

A 23 year old shocked patient is brought to into the Emergency Department Resuscitation room. The Trauma Team are trying to gain vascular access. After 5 minutes of being unable to gain intravenous access you remember a recent training session on a Bone Injection Gun (BIG) and you wonder if this would be better to use than the standard intraosseous needles that you have previously used?

Search Strategy

Medline 1966-01/05 using the OVID interface.
[exp Infusions, Intraosseous OR intraosseous infusion$.mp OR intraosseous.mp OR IO.mp] AND [BIG.mp OR auto-injector.mp OR auto$.mp OR bone injection gun.mp] LIMIT to English

Search Outcome

Altogether 129 papers were found of which 3 were relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Waisman, M. and Waisman, D. February 1997 USA	19 patients for resuscitation in whom iv. access could not be achieved within 10 minutes and 31 adults with fractures receiving regional anaesthesia	Prosepective case series	Success rate	100% successful placement	Observational study with no comparisons. Small numbers. Lack of follow up in resuscitation group
			Time to placement	time taken "1-2 minutes"
			Complications	none in 24 hours or 4 months for respective groups
Calkins MD et al 2000 USA	31 special operations corpsmen testing 4 IO devices on cadavers; BIG, Screw Tip IO Needles. (2 other devices not relevant to the 3 part question so results not given)	Randomised Experimental Trial	Success Rate	BIG 94%, Screw Tip 97% (Not significant)	Using non medical responders. By using cadavers there is no "clinical pressure" to achieve vascular access.
			Time to placement	BIG 70s (SD 33), Screw Tip 88s (SD 33) (Not significant)
			Rank of Preference (1-4)	BIG Average rank 2.3, Screw Tip average rank 2.5 (Not significant)
Olsen D, 2002, USA	Adult dogs randomised to either IO gun or a Jamshidi IO needle; 24 dogs in each group	PRCT (animal)	Successful placement	20/24 for BIG v 23/24 (96%) for the Jamshidi; p=0.3475	Animal study. Anaesthetised subjects. Direct relevance to humans questionable. Single operator did all procedures. They explain increased failure rate for BIG to be due to poor landmark identification rather than device failure
			Average time for placement	22.4s for BIG v 42s for Jamshidi

Comment(s)

There are no published studies looking at the use of the BIG in live adults or children. Though this would be ideal it is unlikely to be achievable as IO placement is a rare event and there would be ethical and consent issues. We must therefore extrapolate data from other models. The paper by Calkins et al shows that the technique itself is easy to learn by non-medical trained responders, this may have implications for its use in prehospital care. This paper also used the screw tipped IO needle as the standard needle but in practice people may be more used to the standard straight needle. Waismann and Waismann suggest that they can be used succesfully in practice. Olsen found a higher failure rate in anaesthetised dogs but explained this was due to poor landmark identification rather than device failure. The differences in time to placement are unlikely to be clinically significant. From a clinical perspective there appears to be little to choose between them and issues such as cost and training may influence local decisions.

Clinical Bottom Line

The Bone Injection Gun appears to be equivalent in terms of success and possibly (but not clinically significantly) faster to use than standard IO needles at achieving IO access.

References

1. Waisman M. Waisman D. Bone Marrow Infusion in adults. Journal of Trauma-Injury Infection and Critical Care 1997 Feb. 42(2):288-93.
2. Calkins MD, Fitzgerald G, Bentley TB, Burris D. Intraosseous infusion devices: a comparison for potential use in special operations. Journal of Trauma-Injury Infection and Critical Care 2000 Jun. 48(6):1068-74.
3. Olsen D, Packer BE, Perrett J, et al. Evaluation of the bone injection gun as a method for intraosseous placement for fluid therpay in adult dogs. Veterinary Surg 2002;31:533–40.