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the bag to keep pressures at or above 300mmHg. Although   4.  Johnson M, Inaba K, Byerly S, et al. Intraosseous infusion as a
              this was a pilot study, one of the two nonexcluded animals in   bridge to definitive access. Am Surg. 2016;82(10):876–880.
              the push­pull group died during infusion and the other had   5.  US Army Institute of Surgical Research. Damage controlled resus­
              a concerning hypotensive episode. The push­pull and dou­  citation at level IIb/III treatment facilities. Joint Theater Trauma
              ble­barrel methods may confer a benefit in speed of transfu­  System Clinical  Practice Guideline.  1 February 2103.  http://jts
                                                                    .amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guide
              sion but should be further studied to determine the effect these   lines_(CPGs)/Damage_Control_Resuscitation_03_Feb_2017
              increased transfusion pressures have on clinical end points like   _ID18.pdf. Accessed August 10, 2018.
              hemolysis, fat emboli, hemodynamic stability, and shear stress   6.  Tøndevold  E,  Eriksen  J,  Jansen  E.  Observations  on  long  bone
              injury to the bony matrix. addition, given the future need for   medullary pressure in relation to mean arterial blood pressure
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              blood transfusion, a combat practice guideline for IO use in   7.  Hulse  EJ,  Thomas  GO.  Vascular  access  on  the  21st  century
              the early echelons of care may be beneficial.         military battlefield.  J R Army Med Corps. 2010;156(Suppl 4):
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              Acknowledgments                                    8.  Plewa MC, King RW, Fenn-Buderer N, et al. Hematologic safety of
              We thank Dr Greg Zarow of the Combat Trauma Research   intraosseous blood transfusion in a swine model of pediatric hem­
              Group for his mentorship, assistance with data interpretation,   orrhagic hypovolemia. Acad Emerg Med. 1995;2(9):799–809.
              and formal presentation. Research data were derived from an   9.  Harris M, Balog R, Devries G. What is the evidence of utility for
                                                                    intraosseous blood transfusion in damage­control resuscitation? J
              approved Naval Medical Center, Portsmouth, Virginia, Insti­  Trauma Acute Care Surg. 2013;75(5):904–906.
              tutional Review Board protocol No. NMCP 2016.0040.  10.  Orlowski JP, Porembka DT, Gallagher JM, et al. Comparison
                                                                    study of intraosseous, central intravenous, and peripheral intrave­
              Presentation                                          nous infusions of emergency drugs. Am J Dis Child. 1990;144(1):
              This study was presented at the 2017 Navy Wide Academic   112–117.
              Research Competition, 25 May 2017, in Portsmouth, Virginia.  11.  Dubick MA, Pteiffer JW, Clifford CB, et al. Comparison of in­
                                                                    traosseous and intravenous delivery of hypertonic saline/dextran
                                                                    in anesthetized, euvolemic pigs.  Ann Emerg Med. 1992;21(5):
              Disclaimer                                            498–503.
              The views expressed in this article are those of the authors and   12.  Looker AC, Borrud LG, Hughes JP, et al. Total body bone area,
              do not necessarily reflect the official policy or position of the   bone mineral content, and bone mineral density for individuals
              Department of the Navy, Department of Defense, or the US   aged 8 years and over: United States, 1999–2006. Vital Health
              Government. We are military service members and employees   Stat 11. 2013;Aug(253):1–78.
              of the US government. This work was prepared as part of our   13.  Simmons CT. Henry Darcy (1803–1858): Immortalised by his
                                                                    scientific legacy. Hydrogeol J. 2008;16(6):1023–1038.
              official duties. Title 17 U.S.C. 105 provides that “Copyright   14.  Gray WG, Miller CT. Examination of Darcy’s law for flow in po­
              protection under this title is not available for any work of the   rous media with variable porosity. Environ Sci Technol. 2004;38
              United States Government.” Title 17 U.S.C. 101 defines a US   (22):5895–5901.
              Government work as a work prepared by a military service   15.  Aerssens J, Boonen S, Lowet G, Dequeker J. Interspecies differ­
              member or employee of the US Government as part of that   ences in bone composition, density, and quality: potential impli­
              person’s official duties.                             cations for in vivo bone research 1. Endocrinology. 1998;139(2):
                                                                    663–670.
                                                                 16.  Tsukamoto T, Pape HC. Animal models for trauma research:
              Disclosure                                            what are the options? Shock. 2009;31(1):3–10.
              The authors have indicated they have no financial relation­  17.  Burgert JM, Mozer J, Williams T, et al. Effects of intraosseous
              ships relevant to this article to disclose.           transfusion of whole blood on hemolysis and transfusion time
                                                                    in a swine model of hemorrhagic shock: a pilot study. AANA J.
              Author Contributions                                  2014;82(3):199–202.
              JDA, JBM, PJR, CMW, JEF, and TGD designed this study. All   18.  National Research Council. Guide For the Care and Use of Lab-
              authors contributed to the literature search. JDA and CMW   oratory Animals. 8th ed. Washington, DC: National Academies
                                                                    Press; 2010.
              managed institutional review board submission. JDA, CMW,   19.  Mitchell AD, Scholz AM, Pursel VG. Total body and regional
              ACW, GAF, and ALK collected data. JDA, JLH, and MRG   measurements of bone mineral content and bone mineral density
              contributed to data analysis. JDA, JBM, JDK, PJR, CMW,   in pigs by dual energy X­ray absorptiometry. J Anim Sci. 2001;79
              and TGD performed data interpretation. JDA JDK, JBM, PJR,   (10):2594–2604.
              CMW, and TGD contributed to writing the manuscript. All   20.  Knudson BK, Hogberg MG, Merkel RA, et al. Developmental
              authors participated in critical revision. All authors approved   comparisons of boars and barrows: II. Body composition and
                                                                    bone development. Anim Sci. 1985;61(4):797–801.
              the final version of the manuscript.               21.  Lairet JR, Bebarta V, Lairet K, et al. 79: Intraosseous pressure
                                                                    infusion comparison using a rapid infusion device and a pressure
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