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green–labeled epinephrine after sternal and tibial IO de- service: a prospective study and review of the literature.
livery in swine during cardiopulmonary (CPR) resuscita- Resuscitation. 2013;84:440–445.
tion, investigators found that sternal IO administration 6. El-Orbany M, Connolly L. Rapid sequence induction
resulted in significantly faster onset and achieved maxi- and intubation: current controversy. Anesth Analg. 2010;
110:1318–1325.
mum plasma concentration more quickly than tibial IO 7. Li J, Murphy-Lavoie H, Bugas C, et al. Complications of
administration. 12
emergency intubation with and without paralysis. Am J
Emerg Med. 1999;17:142–144.
Similar results were found in another pharmacokinetic 8. Shi Y, Hou V, Tucker A, et al. Changes of extremity and
study, in which many of the current study authors were laryngeal muscle electromyographic amplitudes after in-
participants, of epinephrine administered via peripheral travenous administration of vecuronium. Laryngoscope.
IV, sternal IO, and tibial IO routes during cardiac arrest 2008;118:2156–2160.
with ongoing CPR. The investigators found the sternal 9. Hemmerling TM, Schurr C, Walter S, et al. A new method
IO route delivers epinephrine in higher concentrations of monitoring the effect of muscle relaxants on laryngeal
more quickly than the tibial IO route. 13 muscles using surface laryngeal electromyography. Anesth
Analg. 2000;90:494–497.
10. Goldberg ME, Larijani GE, Azad SS, et al. Comparison of
Conclusion tracheal intubating conditions and neuromuscular block-
ing profiles after intubating doses of mivacurium chloride
The onset of muscle paralysis after IO administration of or succinylcholine in surgical outpatients. Anesth Analg.
succinylcholine (3mg/kg) in swine is significantly longer 1989;69:93–99.
compared with IV administration. However, the dura- 11. Moore GP, Pace SA, Busby W. Comparison of intraos-
tion of action of succinylcholine administered via the seous, intramuscular, and intravenous administration of
IO and IV routes are not statistically different from each succinylcholine. Pediatr Emerg Care. 1989;5:209–210.
other. Succinylcholine can be effectively administered 12. Hoskins SL, do Nascimento P Jr, Lima RM, et al. Phar-
via the IO route, but an increased dose may be necessary macokinetics of intraosseous and central venous drug
when administering succinylcholine via the IO route to delivery during cardiopulmonary resuscitation. Resusci-
achieve the same rapid onset as standard IV dosing. tation. 2012;83:107–112.
13. Burgert J, Gegel B, Loughren M, et al. Comparison of
tibial intraosseous, sternal intraosseous, and intravenous
Disclosures routes of administration on pharmacokinetics of epi-
nephrine during cardiac arrest: a pilot study. AANA J.
The authors have no commercial associations that might 2012;80(Suppl):S6–S10.
pose a conflict of interest in connection with this work.

Disclaimer
LTC Loughren is a certified registered nurse anesthetist af-
The opinions expressed in this work are those of the filiated with the Department of Anesthesia and Operative
authors and do not reflect the official policy or position Services, Madigan Army Medical Center, Joint Base Lewis-
of the US Army, the Department of Defense or the US McChord, Washington.
Government.
MAJ Kilbourn is a registered nurse. At the time of this study,
he was a student in the U.S. Army Graduate Program in Nurs-
References ing, Fort Sam Houston, Texas
1. Sarkar D, Philbeck T. The use of multiple intraosseous cath-
eters in combat casualty resuscitation. Mil Med. 2009;174: CPT Worth is a certified registered nurse anesthetist. At the
106–108. time of this study, he was a student in the U.S. Army Graduate
2. Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-os- Program in Nursing, Fort Sam Houston, Texas
seous access (EZ-IO) for resuscitation: UK military combat
experience. J R Army Med Corps. 2007;153:314–316. Dr. Burgert is a certified registered nurse anesthetist and re-
3. Pozza M, Lunardi F, Pflipsen M. Emergency intraosseous search scientist, Geneva Foundation, Tacoma, Washington.
access: a useful, lifesaving device used in afghanistan. J
Spec Oper Med. 2013;13:25–28. Dr. Gegel is a certified registered nurse anesthetist and is af-
4. Burgert JM. Intraosseous infusion of blood products and filiated with Veterans Anesthesia Services, San Antonio, Texas.
epinephrine in an adult patient in hemorrhagic shock.
AANA J. 2009;77:359–363. COL (Ret) Johnson is director of research at the U.S. Army
5. Santos D, Carron PN, Yersin B, Pasquier M. EZ-IO intra- Graduate Program in Anesthesia, Fort Sam Houston, Texas.
®
osseous device implementation in a pre-hospital emergency E-mail: arthurjohnso@gmail.com.

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