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American Journal of Disaster Medicine
Winter 2016, Volume 11
, Number 1


Article
Survey of Emergency Department staff on disaster preparedness and training for Ebola virus disease
Jennica Siddle, MD, MPH; Sue Tolleson-Rinehart, PhD; Jane Brice, MD, MPH
Winter 2016; pages 5-18

Abstract
Introduction: In the domestic response to the outbreak of Ebola virus disease from 2013 to 2015, many US hospitals developed and implemented specialized training programs to care for patients with Ebola. This research reports on the effects of targeted training on Emergency Department (ED) staff's Ebola-related perceptions and attitudes. Methods: One hundred fifty-nine members of the UNC Health Care System ED staff participated in a voluntary cross-sectional, anonymous Web survey administered using a one-time “post then pre” design. Participants responded to questions about risk, roles, willingness to provide care, preparedness, and the contributions of media, training, or time to opinion change using a Likert agree-disagree scale. The authors conducted t test comparisons of Likert responses to pretraining and post-training attitudes about Ebola preparedness. The authors conducted multinomial logistic regression analyses of index scores of change and positivity of responses, controlling for the effects of independent variables. Results: ED staff's opinions supported training; 73 percent felt all workers should receive Ebola education, 60 percent agreed all hospitals should prepare for Ebola, 66 percent felt UNC was better prepared, and 66 percent felt it had done enough to be ready for an Ebola case. Most staff (79 percent) said they had gotten more training for Ebola than for other disease outbreaks; 58 percent had experienced prior epidemics. After training, workers’ attitudes were more positive about Ebola preparation including perceived risk of transmission, readiness and ability to manage a patient case, understanding team roles, and trust in both personal protective equipment and the hospital system's preparations (13 measures, p < 0.0001 to p < 0.001). Overall, total opinion indices also changed significantly over the training period (Mean Difference [MD] = 17.45, SD = 9.89) and in the intended positive direction (MD = 15.80, SD = 0.91, p < 0.0001). Positive change and overall change from pre to post were significantly associated with more hours of training (p = 0.003). Despite different occupations, mean scores were similar. Staff rated training most important and media least important, as the sources of change in their attitudes (p < 0.0001). Conclusions: These findings suggest that disease-specific training for novel pathogens such as Ebola may result in positive staff perceptions of self-efficacy and occupational efficacy to treat potentially infected patients in the ED setting. Training, in this case, outweighed media content in changing staff perceptions of Ebola management. Key words: disaster planning, emergency department, Ebola virus disease, survey, epidemic training DOI:10.5055/ajdm.2016.0220


Article
Impact of Hurricane Sandy on community pharmacies in severely affected areas of New York City: A qualitative assessment
Vibhuti Arya, PharmD, MPH; Eric Medina, MPA; Allison Scaccia, RN; Cathleen Mathew, PharmD; David Starr, MIA
Winter 2016; pages 21-30

Abstract
Hurricane Sandy was one of the most severe natural disasters to hit the Mid-Atlantic States in recent history. Community pharmacies were among the businesses affected, with flooding and power outages significantly reducing services offered by many pharmacies. The objectives of our study were to assess the impact of Hurricane Sandy on community pharmacies, both independently owned and chain, in the severely affected areas of New York City (NYC), including Coney Island, Staten Island, and the Rockaways, using qualitative methods, and propose strategies to mitigate the impact of future storms and disasters. Of the total 52 solicited pharmacies, 35 (67 percent) responded and were included in our analysis. Only 10 (29 percent) of the pharmacies surveyed reported having a generator during Hurricane Sandy; 37 percent reported being equipped with a generator at the time of the survey approximately 1 year later. Our findings suggest that issues other than power outages contributed more toward a pharmacy remaining operational after the storm. Of those surveyed, 26 (74 percent) suffered from structural damage (most commonly in Coney Island). Most pharmacies (71 percent) were able to reopen within 1 month. Despite staffing challenges, most pharmacies (88 percent) had enough pharmacists/staff to resume normal operations. Overall, 91 percent were aware of law changes for emergency medication access, and 81 percent found the information easy to obtain. This survey helped inform our work toward improved community resiliency. Our findings have helped us recognize community pharmacists as important stakeholders and refocus our energy toward developing sustained partnerships with them in NYC as part of our ongoing preparedness strategy. Key words: emergency preparedness, pharmacy, impact, medication access, disaster planning and management, Hurricane Sandy DOI:10.5055/ajdm.2016.0221


Article
A comparison of command center activations versus disaster drills at three institutions from 2013 to 2015
Laura G. Ebbeling, MD; Eric Goralnick, MD, MS; Matthew J. Bivens, MD; Meg Femino, HEM; Claire G. Berube, BA, HEM; Bryan Sears, BS, HEM; Leon D. Sanchez, MD, MPH
Winter 2016; pages 33-42

Abstract
Objective: Disaster exercises often simulate rare, worst-case scenario events that range from mass casualty incidents to severe weather events. In actuality, situations such as information system downtimes and physical plant failures may affect hospital continuity of operations far more significantly. The objective of this study is to evaluate disaster drills at two academic and one community hospital to compare the frequency of planned drills versus real-world events that led to emergency management command center activation. Design: Emergency management exercise and command center activation data from January 1, 2013 to October 1, 2015 were collected from a database. The activations and drills were categorized according to the nature of the event. Frequency of each type of event was compared to determine if the drills were representative of actual activations. Results: From 2013 to 2015, there were a total of 136 command center activations and 126 drills at the three hospital sites. The most common reasons for command center activations included severe weather (25 percent, n = 34), maintenance failure (19.9 percent, n = 27), and planned mass gathering events (16.9 percent, n = 23). The most frequent drills were process tests (32.5 percent, n = 41), hazardous material-related events (22.2 percent, n = 28), and in-house fires (15.10 percent, n = 19). Conclusion: Further study of the reasons behind why hospitals activate emergency management plans may inform better preparedness drills. There is no clear methodology used among all hospitals to create drills and their descriptions are often vague. There is an opportunity to better design drills to address specific purposes and events. Key words: command center, disaster, drill, disaster preparedness, exercises, emergency management DOI:10.5055/ajdm.2016.0222


Article
Women's oral and dental health aspects in humanitarian missions and disasters: Jordanian experience
Leena Smadi, BDS, MDentSci, FDS RCSEd; Aiman Al Sumadi, MD, FRCOG
Winter 2016; pages 43-48

Abstract
Objective: The study aimed to review oral and dental health aspects in female patients presented to Jordanian Royal Medical Services (RMS) international humanitarian missions over a 3-year period. Design and Method: Analysis of humanitarian missions of RMS data and records over a 3-year period (2011-2013) in regard to women's oral and dental health issues was done. The data were analyzed in regard to the number of women seen, the presenting conditions, and the prevalence of oral and dental diseases and procedures in these cases. Results: During the 3-year period, 72 missions were deployed in four locations (Gaza, Ram Allah—West Bank, Jeneen—West Bank, and Iraq). The total number of females seen in this period was 86,436 women, accounting for 56 percent of adult patients seen by RMS humanitarian missions. Dental Clinics were deployed to only two missions (Iraq and Gaza), during which they received 13,629 visits; of these, 41 percent were females (5,588 patients), 29 percent were males, and 30 percent were in the pediatric age group. Trauma accounts for only 7 percent of the cases, while nonacute dental problems (caries and gingivitis) were responsible for the majority of cases (31.6 and 28.7 percent, respectively). Conclusion: RMS dental services during humanitarian mission deployment are a vital part of comprehensive healthcare. Women usually seek more dental care than men, with the majority of treatments for nonacute conditions. RMS experiences demonstrate the tremendous need for a well-defined preparedness plan for deployment of humanitarian missions that considers the contributions of all types of health professionals, the appropriate mobile technology to respond to emergent health risks, and a competent workforce ready and able to respond. Such preparation will require our dental education programs to develop disaster preparedness competencies to achieve the desired level of understanding. Key words: disaster preparedness, first responders, humanitarian missions, military medicine, women's dental health DOI:10.5055/ajdm.2016.0223


Article
Injury-related fatalities in selected governorates of Iraq from 2010 to 2013: Prospective surveillance
Oleg O. Bilukha, MD, PhD; Abdul-Salam Saleh Sultan, MBChB, DM; Ahmed Hassan, MBChB, FICMS; Syed Jaffar Hussain, MD; Eva Leidman, MSPH
Winter 2016; pages 49-58

Abstract
Objective: After several years of relative stability in Iraq, the emergence of the Islamic State militant group has spurred a resurgence of violence. This study explores the impact of the conflict on the overall injury profile to estimate the proportion of injury fatalities related to conflict and better understand how violence has affected nonconflict-related injuries. Design: Routine prospective injury surveillance operated by the Iraqi Ministry of Health. Setting: Surveillance data were collected from coroner offices in eight pilot governorates: Al-Anbar, Baghdad, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. Participants: We analyzed all fatalities from external injury causes recorded between January 1, 2010 and December 31, 2013. Analysis included 32,664 fatal injuries. Results: Of all injury fatalities reported, 27.1 percent were conflict-related fatalities, approximately the same proportion as road traffic-related fatalities (24.4 percent) and other unintentional injuries (27.5 percent). The proportion of fatalities from conflict was approximately three times higher among males than females (33.0 percent and 10.3 percent, respectively) and four times higher among adults than children (29.8 percent and 7.3 percent, respectively). The total number of injury fatalities remained stable between 2010 and 2012; an increase in injury fatalities in 2013 was driven primarily by increases in fatalities from both interpersonal violence and conflict. Conclusions: From 2010 to 2013, nearly one in four injury fatalities in Iraq was attributable to conflict, a notably higher proportion than other conflict-affected countries in the region. The overall profile of nonconflict injuries in Iraq is also distinct from other countries of similar socioeconomic level that have not experienced violence. Key words: death certificates, information systems, international, mortality, surveillance DOI:10.5055/ajdm.2016.0224


Article
Hajj stampede disaster, 2015: Reflections from the frontlines
Anas A. Khan, MBBS, MHA, SBEM, ABHS-EM; Eric K. Noji, MD, MPH, MBA, DTM&H, FACEP, FRCP
Winter 2016; pages 59-68

Abstract
The Hajj is an annual religious mass gathering that takes place in Makkah, Saudi Arabia. The complexity of its system is multidimensional, with religious, political, cultural, security, economic, communication, operational, and logistic unique challenges. This year, yet another stampede tragedy that caused around a 1,000 deaths and severe injuries, capturing worldwide media attention and exacerbating existing political tensions across the Gulf coasts was faced. Planning is important but the planning process is more important, requiring systematic analysis based on accurate collected and targeting root cause factors. Every year, the Hajj provides us with important knowledge and experience that will help preventing such events. This will only be possible if the initiative to extract all possible lessons learned are taken. The medical and public health community in Saudi Arabia must learn from other scientific fields where much more quantitative data-driven approach to identify problems and recommending solutions. Key words: Hajj, Mina, mass gathering, stampede, crowd management DOI:10.5055/ajdm.2016.0225


Article
Social support for terror-related victims: The Israeli system
Eytan Ellenberg, MD, PhD; Jacob Sasporte, LLB; Zvia Bar-on, MD, MHA; Rolland Sfez, LLD; Osnat Cohen; Mark Taragin, MD, MPH; Ishay Ostfeld, MD, MHA
Winter 2016; pages 69-71

Abstract
Since its foundation, the State of Israel has been affected by terror violence toward its civilian population. For more than 45 years, the Israeli legislation has built a legal insurance allowing citizens casualties of such violence to benefit from specific coverage and support. The objective of this article is to describe the history, legal framework, and organization of social support for terror victims in Israel. Key words: terrorism, terror victims, support, disability, legal, Israel DOI:10.5055/ajdm.2016.0226

American Journal of Disaster Medicine
Spring 2016, Volume 11
, Number 2


Article
Surgeon preparedness for mass casualty events: Adapting essential military surgical lessons for the home front
Kyle N. Remick, MD, FACS; Stacy Shackelford, MD; John S. Oh, MD; Jason M. Seery, MD; Daniel Grabo, MD; John Chovanes, DO; Kirby R. Gross, MD; Shawn C. Nessen, DO; Nigel RM Tai, QHS, MS; Rory F. Rickard, PhD; Eric Elster, MD; C. W. Schwab, MD
Spring 2016; pages 77-87

Abstract
Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a matter of routine over the course of the last two conflicts in Afghanistan and Iraq. Over the same period of time, civilian surgeons have increasingly faced complex MCEs on the home front. Our objective is to summarize and adapt these combat surgery lessons to enhance civilian surgeon preparedness for complex MCEs on the home front. The authors describe the unique lessons learned from combat surgery over the course of the wars in Afghanistan and Iraq and adapt these lessons to enhance civilian surgical readiness for a MCE on the home front. Military Damage Control Surgery (mDCS) combines the established concept of clinical DCS (cDCS) with key combat situational awareness factors that enable surgeons to optimally care for multiple, complex patients, from multiple simultaneous events, with limited resources. These additional considerations involve the surgeon's role of care within the deployed trauma system and the battlefield effects. The proposed new concept of mass casualty DCS (mcDCS) similarly combines cDCS decisions with key factors of situational awareness for civilian surgeons faced with complex MCEs to optimize outcomes. The additional considerations for a civilian MCE include the surgeon's role of care within the regional trauma system and the incident effects. Adapting institutionalized lessons from combat surgery to civilian surgical colleagues will enhance national preparedness for complex MCEs on the home front. Key words: mass casualty, damage control, surgeon preparedness, military DOI:10.5055/ajdm.2016.0228


Article
A systems dynamics approach to the efficacy of oxime therapy for mild exposure to sarin gas
Daniel J. Droste, MS; Michael L. Shelley, PhD; Jeffery M. Gearhart, PhD; David M. Kempisty, PhD
Spring 2016; pages 89-118

Abstract
The use of nerve agents such as sarin is as much a threat today as any other time in our history. The events in Syria in 2013 are proof of this. “The Obama administration asserted Sunday for the first time that the Syrian government used the nerve gas sarin to kill more than 1,400 people (August 21, 2013) in the world's gravest chemical weapons attack in 25 years.” With these recent events clear in our mind, we must focus on the horrific nature of these chemical agents to devise a strategy that will enable first responders to counteract these insidious chemicals. This paper presents research on a physiologically based pharmacokinetic model to determine whether the current treatment protocol prescribed by the Center for Disease Control (CDC) and the US Army is effective in treating victims suffering from acute exposure symptoms. The model was used to determine what treatment should be used for victims suffering from mild exposure symptoms. The results indicate that the current CDC and US Army treatment is effective, but treatment with oxime therapy was not effective in alleviating symptoms of mild exposure. By applying these results, an effective treatment protocol was developed. Key words: system dynamics, oxime therapy, nerve agents, physiologically based pharmacokinetics, model DOI:10.5055/ajdm.2016.0229


Article
Time to epinephrine in out-of-hospital cardiac arrest: A retrospective analysis of intraosseous versus intravenous access
Elliot M. Ross, MD; Julian Mapp, MD; Chetan Kharod, MD, MPH; David A. Wampler, PhD, LP; Christopher Velasquez, LP; David A. Miramontes, MD
Spring 2016; pages 119-123

Abstract
Introduction: The 2015 advanced cardiac life support update continues to advocate administering epinephrine during cardiac arrest. The goal of our study is to determine if prehospital intraosseous (IO) access results in shorter time to epinephrine than prehospital peripheral intravenous (PIV) access. Methods: The out-of-hospital cardiac arrest (OHCA) database of a large, urban, fire-based emergency medical services system was searched for consecutive cases of OHCA between January 2013 and December 2015. The time to the first dose of epinephrine was calculated and compared by vascular access technique utilized (PIV or IO). Descriptive statistics were used to report first pass success and IO complications. Results: A total of 3,470 OHCA cases were treated during the study period. Of those cases, 2,656 met our inclusion criteria. There were 2,601 cases of IO usage and 55 cases of PIV usage. The mean time from arrival at the patient's side to administration of the first dose of epinephrine was 5.0 minutes (95% CI: 4.7 minutes, 5.4 minutes) for the IO group and 8.8 minutes (95% CI: 6.6 minutes, 10.9 minutes) for the PIV group (p < 0.001). There were a total of 2,879 IO attempts with 2,753 IOs successfully placed in 2,601 patients. The first pass IO success rate was 95.6 percent (2,753/2,879). Conclusion: In the setting of OHCA, the time to administer the first dose of epinephrine was faster in the IO access group when compared to PIV access group. The prehospital use of IO vascular access for time-dependent medical conditions is recommended. Key words: IO, emergency vascular access, intraosseous, out-of-hospital cardiac arrest DOI:10.5055/ajdm.2016.0230


Article
Hospital incident command: First responders or receiving centers?
Brian Fletcher, MSN, MHA, RN; Amanda Knight, MS; Brandy Pockrus, MSN, RN; Matthew J. Wain, MAS; Kathy Lehman-Huskamp, MD
Spring 2016; pages 125-130

Abstract
Objectives: (1) Propose a conceptual model of an alternative hospital incident management system (HIMS) that integrates concepts used by emergency operations centers (EOCs). (2) Compare HIMS to the standard hospital incident command system (HICS) model. Design: A quasi-experimental study was performed. Two identical tabletop incident scenarios were presented, one utilizing HICS and one using HIMS. Participants completed postexercise surveys for each tabletop. Surveys contained both knowledge and satisfaction questions. The Likert Scale (1 strongly disagree and 5 strongly agree) was utilized for satisfaction questions. Setting: The Medical University of South Carolina (MUSC), a level I trauma and academic center. Participants: N = 16; participants were members of MUSC's Emergency Management Committee. Participation was voluntary. Main Outcome Measures: (1) Knowledge of reporting structure within each model and (2) end-user satisfaction with model implementation. Results: Using the HIMS model, participants correctly answered reporting structure questions 63.75 percent of the time in comparison to the HICS model of 35 percent (p value 0.001). Statistical analysis of qualitative satisfaction data between the two models revealed that HIMS was preferred over the HICS, 87.5 and 33.5 percent, respectively. Conclusions: The HIMs model is a new application for hospital incident management. This article serves to introduce the concept. Using the established EOC framework, continued research in this area is needed to validate the proposed HIMS model and standardize its design. Key words: HIMS, HICS, incident management DOI:10.5055/ajdm.2016.0231


Article
Evacuation performance evaluation tool
Sharon Farra, PhD, RN, CNE; Elaine T. Miller, PhD, RN, CRRN, FAAN; Matthew Gneuhs, CHEP; Nathan Timm, MD; Gengxin Li, PhD; Ashley Simon, RN, MSN; Whittney Brady, DNP, RN
Spring 2016; pages 131-136

Abstract
Objective: Hospitals conduct evacuation exercises to improve performance during emergency events. An essential aspect in this process is the creation of reliable and valid evaluation tools. The objective of this article is to describe the development and implications of a disaster evacuation performance tool that measures one portion of the very complex process of evacuation. Design: Through the application of the Delphi technique and DeVellis's framework, disaster and neonatal experts provided input in developing this performance evaluation tool. Following development, content validity and reliability of this tool were assessed. Setting: Large pediatric hospital and medical center in the Midwest. Participants: The tool was pilot tested with an administrative, medical, and nursing leadership group and then implemented with a group of 68 healthcare workers during a disaster exercise of a neonatal intensive care unit (NICU). Results: The tool has demonstrated high content validity with a scale validity index of 0.979 and inter-rater reliability G coefficient (0.984, 95% CI: 0.948-0.9952). Conclusions: The Delphi process based on the conceptual framework of DeVellis yielded a psychometrically sound evacuation performance evaluation tool for a NICU. Key words: disaster exercise, performance tool, inter-rater reliability, instrument development, evacuation exercise DOI:10.5055/ajdm.2016.0232


Article
Circus disaster: Case report, response, and review of injuries
Nicholas Asselin, DO; Lawrence Proano, MD; Kenneth Williams, MD; Robert Partridge, MD, MPH
Spring 2016; pages 137-141

Abstract
Circus acts with human artists performing acrobatic feats are a popular spectator pastime in the United States and in international venues. There is little data in the literature regarding injuries sustained during circus acts. Some injuries are minor, but others can be serious, or even fatal. This article describes a recent circus disaster, a review of the relevant literature, and an analysis of the disaster response. Key words: disaster, circus, injury, response, review DOI:10.5055/ajdm.2016.0233

American Journal of Disaster Medicine
Summer 2016, Volume 11
, Number 3


Article
Introduction: Special Issues on Intraosseous Medicine - Part 1
Susan M. Briggs, MD, MPH, FACS
Summer 2016; pages 143-143

Abstract
Peripheral intravenous (IV) access can be difficult to achieve in critically ill patients who require vascular access in order to administer life-saving blood products, fluids and medications, especially in disasters and combat casualty care. Intraosseous access (IO) has become the standard of care for all medical emergencies, pre-hospital and hospital, when peripheral IV access cannot be rapidly established, and the techniques have been endorsed by multiple professional medical organizations. Research is rapidly expanding, both in the indications for IO, routes of administration, and clinical outcomes of intraosseous administration. The American Journal of Disaster Medicine is pleased to have the opportunity to publish two Special Issues1 focusing on current intraosseous research studies. Keywords: Intraosseous access, Peripheral intravenous, combat casualty care, disaster medicine DOI:10.5055/ajdm.2016.0252


Article
Intraosseous vascular access in disasters and mass casualty events: A review of the literature
James M. Burgert, DNAP
Summer 2016; pages 149-166

Abstract
Objective: The intraosseous (IO) route of vascular access has been increasingly used to administer resuscitative fluids and drugs to patients in whom reliable intravenous (IV) access could not be rapidly or easily obtained. It is unknown that to what extent the IO route has been used to gain vascular access during disasters and mass casualty events. The purpose of this review was to examine the existing literature to answer the research question, “What is the utility of the IO route compared to other routes for establishing vascular access in patients resulting from disasters and mass casualty events?” Design: Keyword-based online database search of PubMed, CINAHL, and the Cochrane Database of Systematic Reviews. Setting: University-based academic research cell. Evidence Sources: Included evidence were randomized and nonrandomized trials, systematic reviews with and without meta-analysis, case series, and case reports. Excluded evidence included narrative reviews and expert opinion. Main Outcome Measures: Not applicable. Results: Of 297 evidence sources located, 22 met inclusion criteria. Located evidence was organized into four categories including chemical agent poisoning, IO placement, while wearing chemical protective clothing (PPE), military trauma, and infectious disease outbreak. Conclusions: Evidence indicates that the IO route of infusion is pharmacokinetically equal to the IV route and superior to the intramuscular (IM) and endotracheal routes for the administration of antidotal drugs in animal models of chemical agent poisoning while wearing full chemical PPE. The IO route is superior to the IM route for antidote administration during hypovolemic shock. Civilian casualties of explosive attacks and mass shootings would likely benefit from expanded use of the IO route and military resuscitation strategies. The IO route is useful for fluid resuscitation in the management of diarrheal and hemorrhagic infectious disease outbreaks. Key words: chemical agent poisoning, explosive attack, infectious disease epidemic, intraosseous, mass shooting, resuscitation DOI:10.5055/ajdm.2016.0235


Article
A primer on intraosseous access: History, clinical considerations, and current devices
James M. Burgert, DNAP
Summer 2016; pages 167-173

Abstract
Objective: Intraosseous (IO) access is a method recommended by the American Heart Association and the European Resuscitation Council to administer resuscitative drugs and fluids when intravenous (IV) access cannot be rapidly or easily obtained. Many clinicians have limited knowledge or experience with the IO route. The purpose of this review was to provide the reader with a succinct review of the history, clinical considerations, and devices associated with IO access. Design: Narrative review. Setting: University-based academic research cell. Main Outcome Measures: Not applicable. Results: Not applicable. Conclusions: IO access is a lifesaving bridge to definitive vascular access that may be considered when an IV cannot be rapidly attained and the patient's outcome may be negatively affected without prompt circulatory access. The IO route has few contraindications for use and a low rate of serious complications. Multiple manual and powered devices that may be placed in several anatomic sites are commercially available. All clinicians who provide acute care or respond to cardiovascular emergencies should obtain training and maintain proficiency in placing and using IO devices as the IO route is recommended by the major resuscitation organizations as the preferred route of infusion when rapid, reliable IV access is unavailable. Key words: complications, contraindications, indications, intraosseous, resuscitation DOI:10.5055/ajdm.2016.0236


Article
Comparison of the effects of sternal and tibial intraosseous administered resuscitative drugs on return of spontaneous circulation in a swine model of cardiac arrest
Mara O'Sullivan, MS3; Andre Martinez, MS3; Audrey Long, Student; Michelle Johnson, DNP, CRNA; Dawn Blouin, BS; Arthur D. Johnson, PhD; James M. Burgert, DNAP, CRNA
Summer 2016; pages 175-182

Abstract
Objective: Compare vasopressin, amiodarone, and epinephrine administration by sternal intraosseous (SIO), tibial intraosseous (TIO), and intravenous (IV) routes in a swine model of cardiac arrest. Design: Prospective, randomized, between subjects, experimental design. Setting: Laboratory. Subjects: Male Yorkshire-cross swine (N = 35), seven per group. Intervention: Swine were randomized to SIO, TIO, IV, cardiopulmonary resuscitation (CPR) with defibrillation, or CPR-only groups. Ventricular fibrillation (VF) was induced under general anesthesia. Mechanical CPR began 2 minutes postarrest. Vasopressin (40 U) was administered to the SIO, TIO, and IV groups 4 minutes postarrest. Defibrillation was performed and amiodarone (300 mg) was administered 6 minutes postarrest. Defibrillation was repeated, and epinephrine (1 mg) was administered 10 minutes postarrest. Defibrillation was repeated every 2 minutes and epinephrine repeated every 4 minutes until return of spontaneous circulation (ROSC) or 26 postarrest minutes elapsed. Main Outcome Measures: Rate of ROSC, time to ROSC, and odds of ROSC. Results: There were no significant differences in rate of ROSC between the SIO and TIO (p = 0.22) or IV groups (p = 1.0). Time to ROSC was five times less in the SIO group than the TIO group (p = 0.003) but not compared to IV (p = 0.125). Time to ROSC in the IV group was significantly less than the TIO group (p = 0.04). Odds of ROSC for the SIO group were five times higher compared to the TIO group but same as IV. Odds of ROSC in the IV group were higher than the TIO group. Conclusion: There was a statistically significant delay in the time to ROSC and a clinically significant difference in odds of ROSC when resuscitative drugs, including lipophilic amiodarone, were administered by the TIO route compared to the SIO and IV routes in a swine model of sudden cardiac arrest. Further investigations are warranted to isolate the mechanism behind these findings. Key words: amiodarone, epinephrine, intraosseous, resuscitation, return of spontaneous circulation, vasopressin DOI:10.5055/ajdm.2016.0237


Article
Effects of intravenous, sternal, and humerus intraosseous administration of Hextend on time of administration and hemodynamics in a hypovolemic swine model
Dawn Blouin, BS; Brian T. Gegel, DNAP, CRNA; Don Johnson, PhD; Jose C. Garcia-Blanco, MD
Summer 2016; pages 183-192

Abstract
Objective: To determine if there were significant differences among humerus intraosseous (HIO), sternal intraosseous (SIO), and intravenous (IV) administration of 500 mL Hextend in hemodynamics or administration time in a hypovolemic swine model. Setting: Vivarium. Subjects: Yorkshire swine; sample size was based on a large effect size of 0.5, an a of 0.05, and a power of 80 percent Swine were randomly assigned to one of four groups: HIO (n = 9), SIO (n = 9), IV (n = 9), and control (n = 9). Intervention: Swine were exsanguinated 30 percent of their blood volume. Hextend (500 mL) was administered by either the HIO, SIO, or IV route; the control group received none. Main Outcome: Time of administration of Hextend; systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), and stroke volume (SV) data were collected every 2 minutes and compared by group over 8 minutes. Results: A repeated analysis of variance found that there were no significant differences in SBP, DBP, MAP, HR, CO, and SV among HIO, SIO, and IV groups over 8 minutes (p > 0.05). An analyses of variance determined that there was no significant difference between groups relative to time of administration (p = 0.521). Conclusion: When IV access is difficult, both HIO and SIO are effective techniques for rapid vascular access and the administration of Hextend for patients in hypovolemic shock. Key words: Hextend, intraosseous, hypovolemic shock DOI:10.5055/ajdm.2016.0238


Article
Effects of tibial intraosseous and intravenous administration of Hextend on time of administration and hemodynamics in a hypovolemic swine model
James Wilson, BSN; Alex Passmore, BSN; Sephra Leger, BSN; Johnathon Lannan, BSN; Michael Bentley, PhD; Don Johnson, PhD
Summer 2016; pages 193-201

Abstract
Objective: To determine if there were significant differences between the tibial intraosseous (TIO) and intravenous (IV) administration of Hextend relative to time and in hemodynamics in a hypovolemic model. Setting: Vivarium. Subjects: Yorkshire swine; sample size was based on a power of 80 percent, a of 0.05, and a large effect size of 0.6. Swine were randomly assigned to one of three groups: TIO (n = 7), IV (n = 7), and control (n = 7). Intervention: Swine were exsanguinated 30 percent of their blood volume. Hextend (500 mL) was administered either by the TIO or IV route; the control group received none. Main Outcome: Time of administration of Hextend; systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), and stroke volume (SV) data were collected every 2 minutes and compared by group over 8 minutes. Results: An independent t test determined that there was no significant difference between groups relative to time of administration (p = 0.001). A repeated analysis of variance found that there were no significant differences in SBP, DBP, MAP, HR, CO, and SV between the TIO and IV groups over 8 minutes (p > 0.05) but significant differences between both TIO and IV compared to the control group (p < 0.05). Conclusion: TIO is an effective and easily used method to administer Hextend for patients in hypovolemic shock. Based upon the findings of this study, the TIO route might be considered the first choice for rapid vascular access and the administration of Hextend. Key words: Hextend, intraosseous, hypovolemic shock DOI:10.5055/ajdm.2016.0239


Article
The effects of sternal and intravenous vasopressin administration on pharmacokinetics
Donald J. Vallier, BSN; Ashley D. Torrence, BSN; Robinson Stevens III, BSN; Peta Noreen Arcinue, BSN; Don Johnson, PhD
Summer 2016; pages 203-209

Abstract
Objective: Purposes of this study were to compare intravenous (IV) and sternal intraosseous (SIO) administration of vasopressin relative to concentration maximum (Cmax), time to maximum concentration (Tmax), and mean concentration in a cardiac arrest model. Design: Prospective, between subjects, randomized experimental design. Setting: Vivarium. Subjects: Yorkshire-cross swine (N = 16) Intervention: Swine were anesthetized, placed into cardiac arrest, and after 2 minutes, cardiopulmonary resuscitation was initiated. After additional 2 minutes, 40 units of vasopressin was administered either by SIO or IV route. Blood samples were collected over 4 minutes. Cmax and means were analyzed using high-performance liquid chromatography tandem mass spectrometry. Main outcome Measurements: Cmax, Tmax, and mean plasma concentrations. Results: There were no significant differences in the SIO and IV groups in Cmax (p = 0.96) or Tmax (p = 0.27). The IV and SIO group had a mean Cmax of 68,151 ± SD 21,534 and 69,034 ± SD 40,169 pg/mL, respectively. The IV and SIO vasopressin groups had a mean Tmax of 105 ± SD 39 and 80 ± SD 41 seconds, respectively. Conclusion: A multivariate analyses of variance indicated that there were no statistically significant differences in pretest data, Cmax, and Tmax; a repeated analyses of variance indicated that there were no significant differences between the groups relative to mean concentrations of serum vasopressin over time (p > 0.05). Conclusion: When a patient is in cardiac arrest, it is essential to establish rapid and reliable access to blood vessels so that life-saving drugs can be administered and the SIO provides such a route. Key words: intraosseous, vasopressin, shock, arrest DOI:10.5055/ajdm.2016.0240


Article
Effects of tibial and humerus intraosseous and intravenous vasopressin in porcine cardiac arrest model
Timothy S. Adams, DNP, CRNA; Dawn Blouin, BS; Don Johnson, PhD
Summer 2016; pages 211-218

Abstract
Objective: Compare maximum concentration (Cmax), time to maximum concentration (Tmax), mean serum concentration of vasopressin, return of spontaneous circulation (ROSC), time to ROSC, and odds of survival relative to vasopressin administration by tibial intraosseous (TIO), humerus intraosseous (HIO), and intravenous (IV) routes in a hypovolemic cardiac arrest model. Design: Prospective, between subjects, randomized experimental design. Setting: TriService Research Facility. Subjects: Yorkshire-cross swine (n = 40). Intervention: Swine were anesthetized, exsanguinated to a Class III hemorrhage, and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After an additional 2 minutes, a dose of 40 units of vasopressin was administered by TIO, HIO, or the IV routes. Blood samples were collected over 4 minutes and analyzed by high-performance liquid chromatography tandem mass spectrometry. Main Outcome Measurements: ROSC, time to ROSC, Cmax, Tmax, mean concentrations over time, and odds ratio. Results: There was no significant difference in rate of ROSC or time to ROSC between the TIO, HIO, and IV groups (p > 0.05). The Cmax was significantly higher in the IV group compared to the TIO group (p = 0.015), but no significant difference between the TIO versus HIO or HIO versus IV groups (p > 0.05). The Tmax was significantly shorter for the HIO compared to the TIO group (p = 0.034), but no significant differences between the IV group compared to the TIO or HIO groups (p > 0.05). The odds of survival were higher in the HIO group compared to all other groups. Conclusion: The TIO and HIO provide rapid and reliable access to administer life-saving medications during cardiac arrest. Key words: intraosseous, return of spontaneous circulation, pharmacokinetics, resuscitation, hemorrhage, vasopressin DOI:10.5055/ajdm.2016.0241

American Journal of Disaster Medicine
Fall 2016, Volume 11
, Number 4


Article
Introduction: Special Issues on Intraosseous Medicine - Part 2
Susan M. Briggs, MD, MPH, FACS
Fall 2016; pages 219-219

Abstract
Peripheral intravenous (IV) access can be difficult to achieve in critically ill patients who require vascular access in order to administer life-saving blood products, fluids and medications, especially in disasters and combat casualty care. Intraosseous access (IO) has become the standard of care for all medical emergencies, pre-hospital and hospital, when peripheral IV access cannot be rapidly established, and the techniques have been endorsed by multiple professional medical organizations. Research is rapidly expanding, both in the indications for IO, routes of administration, and clinical outcomes of intraosseous administration. The American Journal of Disaster Medicine is pleased to have the opportunity to publish two Special Issues1 focusing on current intraosseous research studies. Keywords: Intraosseous access, Peripheral intravenous, combat casualty care, disaster medicine DOI:10.5055/ajdm.2016.0252


Article
En route intraosseous access performed in the combat setting
Shelia Savell, PhD, RN; Alejandra G. Mora, BS; Crystal A. Perez, RN, BSN; Vikhyat S. Bebarta, MD; Maj Joseph K. Maddry, MD
Fall 2016; pages 225-231

Abstract
Objective: To describe and compare vascular access practices used by en route care providers during medical evacuation (MEDEVAC). Design: This was a retrospective cohort study. Medical records of US military personnel injured in combat and transported by MEDEVAC teams were queried. Patients: The subjects were transported by military en route care providers, in the combat theater during Operation Enduring Freedom (OEF) between January 2011 and March 2014. The authors reviewed 1,267 MEDEVAC records of US casualties and included 832 subjects that had vascular access attempts. Main outcome measures: The outcome measures for this study were vascular access success rates, including intravenous (IV) and intraosseous (IO) attempts. Subjects were grouped by type of vascular access: None, peripheral intravenous (PIV), IO, and PIV + IO (combination of PIV and IO) and by vascular access (PIV or IO) success (No versus Yes). Survival rate, in-flight events, ventilator, intensive care and in hospital days, and 30-day outcomes were compared among groups. Statistical analysis: The authors used chi-square or Fisher's exact tests to evaluate categorical variables. Analysis of variance (ANOVA) or Kruskal-Wallis tests were used for continuous variables. Results: Vascular access was attempted in 832 (66 percent) of the 1,267 subjects transported by MEDEVAC during this study period. The majority (n = 758) of the access attempts were PIV of which 93 percent (706/758) were successful. In 74 subjects, IO was the only access attempted with an 85 percent (n = 63) success rate. The overall success rate with IO placement was 88 percent. Conclusions: Intraosseous access has been used successfully in the combat setting and accounts for approximately 12 percent of vascular access in the MEDEVAC population the authors studied. Key words: vascular access, intraosseous, prehospital, en route care, military medicine, war, combat DOI:10.5055/ajdm.2016.0243


Article
Pharmacokinetics of sternal intraossesous atropine administration in normovolemic and hypovolemic swine
Mark Cornell, MSN, CRNA; Jaime Kelbaugh, MSN, CRNA; Brian Todd, MSN, CRNA; Krista Christianson, MSN, CRNA; Kevin Grayson, DVM, PhD; Joseph O'Sullivan, CRNA, PhD; Don Johnson, RN, PhD; Michael Loughren, CRNA, PhD
Fall 2016; pages 233-236

Abstract
Objective: Characterize and compare the pharmacokinetics of atropine administered via the sternal intraosseous (IO) route in a normovolemic and hypovolemic swine model. Design: Prospective, experimental study. Setting: Vivarium. Subjects: Yorkshire-cross swine (N = 12). Intervention: Atropine was administered via the sternal IO route to normovolemic and hypovolemic swine. Blood samples were drawn at regular intervals after atropine administration and analyzed for plasma atropine concentration. Pharmacokinetic parameters were obtained from modeling the plasma concentrations. Main Outcome Measurements: Pharmacokinetic parameters, maximum concentration (Cmax), and time to maximum concentration (Tmax). Results: The normovolemic and hypovolemic models reached peak plasma concentration immediately and had a very rapid distribution phase with no apparent absorption phase for the IO groups. The hypovolemic group had slower clearance and longer half-life compared to the normovolemic group. Conclusion: The sternal IO route is an effective method of administering atropine and is comparable to the previously reported tibial IO and intravenous data even under conditions of significant hemorrhage. Key words: intraosseous, sternal, atropine, nerve agent, shock, pharmacokinetics DOI:10.5055/ajdm.2016.0244


Article
The comparison of humeral intraosseous and intravenous administration of vasopressin on return of spontaneous circulation and pharmacokinetics in a hypovolemic cardiac arrest swine model
Mark H Wimmer, BSN; Kenneth Heffner, BSN; Michael Smithers, BSN; Richard Culley, BSN; Jennifer Coyner, PhD, CRNA; Michael Loughren, PhD, CRNA; Don Johnson, PhD
Fall 2016; pages 237-242

Abstract
Introduction: The American Heart Association (AHA) recommends intravenous (IV) or intraosseous (IO) vasopressin in Advanced Cardiac Life Support (ACLS). Obtaining IV access in hypovolemic cardiac arrest patients can be difficult, and IO access is often obtained in these life threatening situations. No studies have been conducted to determine the effects of humeral IO (HIO) access with vasopressin in the return of spontaneous circulation (ROSC). Our study compared the kinetics of vasopressin and ROSC with HIO with IV access in the hypovolemic swine model. Methods: Twenty-two Yorkshire swine were divided into three groups: HIO (n = 7), IV (n = 8), and a control group (n = 7). The IV and HIO group received vasopressin and cardiopulmonary resuscitation (CPR), while the control group received only CPR. All subjects were exsanguinated 31 percent of their blood volume, placed in cardiac arrest, and resuscitated per ACLS. Subjects that achieved ROSC were then monitored for 20 minutes. Blood samples (10 mL) collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes after vasopressin injection and analyzed for maximum concentration (Cmax) and time to maximum concentration (Tmax). Data were analyzed using a multivariate analysis of variance (MANOVA) and a Fisher's Exact Test. Results: ROSC was achieved in every subject that received vasopressin via the HIO route. Data analysis using a MANOVA pairwise comparison revealed no difference between mean Cmax (p = 0.601) and Tmax (p = 0.771) of vasopressin administered IV versus HIO routes. Analysis of the mean serum concentrations at time intervals using a repeated measures analysis of variance found no difference (p > 0.05). A Fisher's Exact Test revealed no difference in rate of ROSC between HIO and IV groups (p > 0.05). Odds ratio determined that there was a 33 times higher chance of survival among HIO subjects versus control (CPR and Defibrillation; p = 0.03) and no difference in the survivability of the HIO or IV groups (p = 0.52). Conclusion: The data from this study strongly suggest that there is no significant difference in ROSC, time to ROSC, hemodynamics, or pharmacokinetics between HIO vasopressin and IV vasopressin. This research reinforces current AHA guidelines recommending the use of HIO route early over delaying care awaiting IV access. Key words: intraosseous, humerus, vasopressin, cardiac arrest, cardiopulmonary resuscitation, pharmacokinetics DOI:10.5055/ajdm.2016.0245


Article
Effects of tibial and humerus intraosseous administration of epinephrine in a cardiac arrest swine model
LTC Denise Beaumont, MSN, CRNA; Asal Baragchizadeh, MS; Charles Johnson, MA; Don Johnson, PhD
Fall 2016; pages 243-251

Abstract
Objective: Compare maximum concentration (Cmax), time to maximum concentration (Tmax), mean serum concentration of epinephrine, return of spontaneous circulation (ROSC), time to ROSC, and odds of survival relative to epinephrine administration by humerus intraosseous (HIO), tibial intraosseous (TIO), and intravenous (IV) routes in a swine cardiac arrest model. Design: Prospective, between subjects, randomized experimental design. Setting: TriService Research Facility. Subjects: Yorkshire-cross swine (n = 28). Intervention: Swine were anesthetized and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After an additional 2 minutes, a dose of 1 mg of epinephrine was administered by HIO, TIO, or the IV routes. Blood samples were collected over 4 minutes and analyzed by high-performance liquid chromatography tandem mass spectrometry. Main Outcome Measurements: ROSC, time to ROSC, Cmax, Tmax, mean concentrations over time, and odds ratio. Results: There was no significant difference in rate of the ROSC among the TIO, HIO, and IV groups (p > 0.05). There were significant differences in Cmax: the HIO group was significantly higher than the TIO group (p = 0.007), but no significant difference between the IV and HIO (p = 0.33) or the IV and TIO group (p = 0.060). The Tmax was significantly shorter for both the IV and HIO versus the TIO group (p < 0.05), but no difference between IV and HIO (p = 0.328). The odds of survival were higher in the HIO group compared to all other groups. Conclusion: The TIO and HIO provide rapid and reliable access to administer life-saving medications during cardiac arrest. Key words: intraosseous, return of spontaneous circulation, pharmacokinetics, resuscitation, epinephrine DOI:10.5055/ajdm.2016.0246


Article
The effects of tibial intraosseous versus intravenous amiodarone administration in a hypovolemic cardiac arrest procine model
Kathryn Hampton, BSN; Eric Wang, BSN; Jerome Ivan Argame, BSN; Tom Bateman, BSN;William Craig, DNP, CRNA; Don Johnson, PhD
Fall 2016; pages 253-260

Abstract
Objective: This study compared the effects of amiodarone via tibial intraosseous (TIO) and intravenous (IV) routes on return of spontaneous circulation (ROSC), time to ROSC, maximum drug concentration (Cmax), time to maximum concentration (Tmax), and mean concentrations over time in a hypovolemic cardiac arrest model. Design: Prospective, between subjects, randomized experimental design. Setting: TriService Research Facility. Subjects: Yorkshire-cross swine (n = 28). Intervention: Swine were anesthetized and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation (CPR) was initiated. After an additional 2 minute, 300 mg of amiodarone were administered via the TIO or the IV route. Blood samples were collected over 5 minutes. The plasma concentrations were analyzed using high-performance liquid chromatography tandem mass spectrometry. Main Outcome Measurements: ROSC, time to ROSC, Cmax, Tmax, and mean concentrations over time. Results: A multivariate analysis of variance indicated that there were no significant differences in the TIO and IV groups in ROSC (p = 0.515), time to ROSC (p = 0.300), Cmax (p = 0.291), or Tmax (p = 0.475). The mean Cmax of the TIO group was 56,292 ± 11,504 ng/mL compared to 74,258 ± 11,504 ng/mL for the IV group. The Tmax for TIO and IV groups were 120 ± 25 and 94 ± 25, respectively. A repeated measures analysis of variance indicated that there were no significant differences between the groups relative to concentrations over time (p > 0.05). Conclusion: The TIO provides rapid and reliable access to administer lifesaving medications during cardiac arrest. Key words: amiodarone, intraosseous, return of spontaneous circulation, pharmacokinetics, resuscitation, hemorrhage DOI:10.5055/ajdm.2016.0247


Article
Effects of humerus intraosseous versus intravenous amiodarone administration in a hypovolemic porcine model
CPT Monica M. Holloway, BSN; CPT Shannan L. Jurina, MSN; CPT Joshua D. Orszag, BSN; 1LT George R. Bragdon, MS; 1LT Rustin D. Green, BSN, CCRN; Jose C. Garcia-Blanco, MD; Brian E. Benham, DNP, CRNA; LTC Timothy S. Adams, DNP, CRNA; Don Johnson, PhD
Fall 2016; pages 261-269

Abstract
Objective: To compare the effects of amiodarone administration by humerus intraosseous (HIO) and intravenous (IV) routes on return of spontaneous circulation (ROSC), time to maximum concentration (Tmax), maximum plasma drug concentration (Cmax), time to ROSC, and mean concentrations over time in a hypovolemic cardiac arrest model. Design: Prospective, between subjects, randomized experimental design. Setting: TriService Research Facility. Subjects: Yorkshire-cross swine (n = 28). Intervention: Swine were anesthetized and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After an additional 2 minutes, amiodarone 300 mg was administered via the HIO or the IV route. Blood samples were collected over 5 minutes. The samples were analyzed using high-performance liquid chromatography tandem mass spectrometry. Main Outcome Measurements: ROSC, Tmax, Cmax, time to ROSC, and mean concentrations over time. Results: There was no difference in ROSC between the HIO and IV groups; each had five achieve ROSC and two that did not (p = 1). There was no difference in Tmax (p = 0.501) or in Cmax between HIO and IV groups (p = 0.232). Means ± standard deviations in seconds were 94.3 ± 78.3 compared to 115.7 ± 87.3 in the IV versus HIO groups, respectively. The mean ± standard deviation in nanograms per milliliter for the HIO was 49,041 ± 21,107 and 74,258 ± 33,176 for the IV group. There were no significant differences between the HIO and IV groups relative to time to ROSC (p = 0.220). A repeated analysis of variance indicated that there were no significant differences between the groups relative to concentrations over time (p > 0.05). Conclusion: The humerus intraosseous provides rapid and reliable access to administer life-saving medications during cardiac arrest. Key words: Amiodarone, intraosseous, return of spontaneous circulation, pharmacokinetics, resuscitation, hemorrhage DOI:10.5055/ajdm.2016.0248


Article
The effects of sternal intraosseous and intravenous administration of amiodarone in a hypovolemic swine cardiac arrest model
Samuel Smith, BSN; Bradley Borgkvist, BSN; Teara Kist, BSN; Jason Annelin, BSN; Don Johnson, PhD; Robert Long, PhD, CRNA
Fall 2016; pages 271-277

Abstract
Objective: This study compared the effects of amiodarone via sternal intraosseous (SIO) and intravenous (IV) routes on return of spontaneous circulation (ROSC), time to ROSC, concentration maximum (Cmax), time to maximum concentration (Tmax), and mean concentrations over time in a hypovolemic cardiac arrest model. Design: Prospective, between subjects, randomized experimental design. Setting: TriService Research Facility. Subjects: Yorkshire-cross swine (n = 28). Intervention: Swine were anesthetized and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After an additional 2 minutes, amiodarone 300 mg was administered via the tibial intraosseous TIO or the IV route. Blood samples were collected over 5 minutes. The plasma concentrations were analyzed using high-performance liquid chromatography tandem mass spectrometry. Main Outcome Measurements: ROSC, time to ROSC, Cmax, Tmax, and mean concentrations over time. Results: A multivariate analyses of variance indicated that there were no significant differences in the SIO and IV groups in ROSC (p = 0.191), time to ROSC (p > 0.05), Tmax mean 88.1 ± 24.8 seconds versus 49.5 ± 21.8 seconds (p = 0.317), or Cmax mean 92,700 ± 161,112 ng/mL versus 64,159.8 ± 14,174.8 ng/mL (p = 0.260). A repeated analyses of variance indicated that there were no significant differences between the groups relative to concentrations over time (p > 0.05). Conclusion: The SIO provides rapid and reliable access to administer life-saving medications during cardiac arrest. Key words: amiodarone, intraosseous, return of spontaneous circulation, pharmacokinetics, resuscitation, hemorrhage DOI:10.5055/ajdm.2016.0249


Article
Onset and duration of intravenous and intraosseous rocuronium in hypovolemic swine
Miguel Nemeth, MSN; George N. Williams III, MSN; Debbie Prichard, MSN; Angie McConnico, BSN; Don Johnson, PhD; Michael Loughren, PhD
Fall 2016; pages 279-282

Abstract
Objective: Compare the onset and duration of rocuronium administered via the intravenous (IV), and intraosseous (IO) routes in a hypovolemic swine model. Design: Prospective, between subjects, experimental study. Setting: Vivarium. Subjects: Yorkshire-cross swine (N = 8). Intervention: Electromyography (EMG) amplitudes were recorded at baseline and for every 15 seconds after administering 1.2 mg/kg of rocuronium via IV or IO routes to hypovolemic swine. EMG amplitudes were measured until termination of EMG activity and then measured every 5 minutes until there was a return to baseline values. Individual data were transformed to percent baseline. Main Outcome Measurements: The time from the end of injection to 90 percent reduction of baseline EMG activity (Onset90), the time to maximum reduction (Onsetpeak), and the maximum reduction of the neuromuscular response (peak effect), as well as, time from the end of injection to the return of 25, 50, 75, and 95 percent of baseline EMG activity was used to characterize onset and recovery of neuromuscular function. Results: Maximum reduction, Onset 90 and Onset peak times were not statistically different between groups. The IV group's mean time to recovery of all benchmarks was faster than the IO group. The IO group took statistically longer than the IV group to return to 25, 50, 75, and 95 percent of baseline activity. Conclusion: The IO route is an effective method of administering rocuronium and is comparable to the IV route even under conditions of significant hemorrhage. Key words: intraosseous, rocuronium, pharmacokinetics, hypovolemia, hemorrhage, trauma; DOI:10.5055/ajdm.2016.0250