IN BRIEF
• Suggests the tibial intraosseous access is an alternative to the venous access.
RESEARCH
Peripheral venous or tibial intraosseous access for medical emergency treatment in the dental office?
• Explains that the tibial intraosseous
access may serve as a rescue procedure available for dentists when treating a medical emergency and a venous access is not possible. • Highlights that the method offers the application of medication in cases when fluid has to be given.
C. Goldschalt,1 S. Doll,1 B. Ihle,1 J. Kirsch1 and T. S. Mutzbauer*1,2 Background The anterior tibia has been recommended as emergency vascular access site if the intravenous route cannot be used. Objective This study aims to evaluate the peripheral venous and anterior tibial intraosseous puncture as alternatives for dentists, using a human and a cadaver model. Method One group of dental students performed a venipuncture by using a standard catheter device (n = 21) on other students. Another group (n = 24) used the Vidacare EZ-IO intraosseous kit on a cadaver tibia with india ink as a tracer. Success rates as well as the time needed for a successful puncture were recorded. Results 28.5% of venous and 83.3% of intraosseous punctures were successful. The relative risk of venous cannulation failure was 3.4 (95% CI 1.6–7.2; p = 0.0005). A successful venous access could be performed within 163 ± 23.2 seconds (mean ± SD), a tibial intraosseous access within 30 ± 27.8 seconds (p = 0.0003). Conclusions Within the limitation of this study, it can be demonstrated that the chances to perform a successful vascular access for inexperienced dentists may be higher when using the tibial intraosseous route for emergency intravascular medication.
INTRODUCTION Emergency situations requiring intravascular medication are assumed to happen rarely in dental facilities.1 If possible, emergencies should be treated using easy strategies such as intraoral, inhalational or intramuscular applications.2 In severe anaphylaxis, intramuscular adrenaline application is recommended.3 Intramuscular puncture may be much easier for dentists, compared to intravenous cannulation. However, a second line measure in severe anaphylaxis is intravascular fluid support.3 In student education it has been demonstrated, that up to 46 venous cannulations were required to prove competency.4 As dentists’ daily work does not cover venous cannulation, this route may not be available for treatment. Even experienced emergency physicians may encounter challenging situations when a venous access is not possible. Recently, the tibial intraosseous access has been recommended also for the experienced healthcare University of Heidelberg, Institute for Anatomy and Cell Biology, Im Neuenheimer Feld 307, D-69120 Heidelberg, Germany; 2Mutzbauer and Partner, Maxillofacial Surgery and Dental Anaesthesiology, Tiefenhoefe 11, CH-8001 Zurich, Switzerland *Corresponding author: Dr Till S. Mutzbauer Email: [email protected] Tel: +41 442 111465
1
Online article number E16 Refereed Paper - accepted 19 February 2015 DOI: 10.1038/sj.bdj.2015.384 © British Dental Journal 2015; 218: E16
provider in the emergency medical service in cases of difficult venous access.5 The anterior tibia, 6 the humerus,7 the radius,8 as well as the manubrium sterni9,10 have been scientifically evaluated and used pre-clinically as well as in hospital as sites for an intraosseous access. The purpose of the present study was to compare the capabilities of dental students to establish either an intravenous access at the forearm or the hand of healthy volunteers versus a tibial intraosseous access in a cadaver. Two null hypotheses were tested: • There would be no differences in success rates comparing both procedures • There would be no differences in times needed to perform each procedure.
METHODS The study participants were dental students of the first clinical year of two universities and had been educated in emergency medical procedures by the same instructor (T. S. M.). None of the test persons had ever performed a venous or intraosseous vascular access procedure before the test. To avoid carry over effects as well as preparedness of individual participants to perform the respective procedure, no cross over design was chosen. A sample size estimate had been performed using G*Power (version 3.1.7). It had been assumed that venous punctures would
BRITISH DENTAL JOURNAL
be performed with a higher rate of failure, approximately 25% of punctures being successful, compared to the intraosseous tibial punctures, approximately 75% being successful. At α
• Suggests the tibial intraosseous access is an alternative to the venous access.
RESEARCH
Peripheral venous or tibial intraosseous access for medical emergency treatment in the dental office?
• Explains that the tibial intraosseous
access may serve as a rescue procedure available for dentists when treating a medical emergency and a venous access is not possible. • Highlights that the method offers the application of medication in cases when fluid has to be given.
C. Goldschalt,1 S. Doll,1 B. Ihle,1 J. Kirsch1 and T. S. Mutzbauer*1,2 Background The anterior tibia has been recommended as emergency vascular access site if the intravenous route cannot be used. Objective This study aims to evaluate the peripheral venous and anterior tibial intraosseous puncture as alternatives for dentists, using a human and a cadaver model. Method One group of dental students performed a venipuncture by using a standard catheter device (n = 21) on other students. Another group (n = 24) used the Vidacare EZ-IO intraosseous kit on a cadaver tibia with india ink as a tracer. Success rates as well as the time needed for a successful puncture were recorded. Results 28.5% of venous and 83.3% of intraosseous punctures were successful. The relative risk of venous cannulation failure was 3.4 (95% CI 1.6–7.2; p = 0.0005). A successful venous access could be performed within 163 ± 23.2 seconds (mean ± SD), a tibial intraosseous access within 30 ± 27.8 seconds (p = 0.0003). Conclusions Within the limitation of this study, it can be demonstrated that the chances to perform a successful vascular access for inexperienced dentists may be higher when using the tibial intraosseous route for emergency intravascular medication.
INTRODUCTION Emergency situations requiring intravascular medication are assumed to happen rarely in dental facilities.1 If possible, emergencies should be treated using easy strategies such as intraoral, inhalational or intramuscular applications.2 In severe anaphylaxis, intramuscular adrenaline application is recommended.3 Intramuscular puncture may be much easier for dentists, compared to intravenous cannulation. However, a second line measure in severe anaphylaxis is intravascular fluid support.3 In student education it has been demonstrated, that up to 46 venous cannulations were required to prove competency.4 As dentists’ daily work does not cover venous cannulation, this route may not be available for treatment. Even experienced emergency physicians may encounter challenging situations when a venous access is not possible. Recently, the tibial intraosseous access has been recommended also for the experienced healthcare University of Heidelberg, Institute for Anatomy and Cell Biology, Im Neuenheimer Feld 307, D-69120 Heidelberg, Germany; 2Mutzbauer and Partner, Maxillofacial Surgery and Dental Anaesthesiology, Tiefenhoefe 11, CH-8001 Zurich, Switzerland *Corresponding author: Dr Till S. Mutzbauer Email: [email protected] Tel: +41 442 111465
1
Online article number E16 Refereed Paper - accepted 19 February 2015 DOI: 10.1038/sj.bdj.2015.384 © British Dental Journal 2015; 218: E16
provider in the emergency medical service in cases of difficult venous access.5 The anterior tibia, 6 the humerus,7 the radius,8 as well as the manubrium sterni9,10 have been scientifically evaluated and used pre-clinically as well as in hospital as sites for an intraosseous access. The purpose of the present study was to compare the capabilities of dental students to establish either an intravenous access at the forearm or the hand of healthy volunteers versus a tibial intraosseous access in a cadaver. Two null hypotheses were tested: • There would be no differences in success rates comparing both procedures • There would be no differences in times needed to perform each procedure.
METHODS The study participants were dental students of the first clinical year of two universities and had been educated in emergency medical procedures by the same instructor (T. S. M.). None of the test persons had ever performed a venous or intraosseous vascular access procedure before the test. To avoid carry over effects as well as preparedness of individual participants to perform the respective procedure, no cross over design was chosen. A sample size estimate had been performed using G*Power (version 3.1.7). It had been assumed that venous punctures would
BRITISH DENTAL JOURNAL
be performed with a higher rate of failure, approximately 25% of punctures being successful, compared to the intraosseous tibial punctures, approximately 75% being successful. At α
