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Stratifying sites according to flow rate is useful when high- There are substantial data that support using an IO line when
volume resuscitation is required. As previously discussed, peripheral IV access is not attainable for various reasons.
sternal and humoral sites have distinct flow rate advantages. However, in our opinion, there is no formal stratification to
Consistent with Wolf’s law, iliac crest access would also have a help determine preferential location for access placement. The
theoretical advantage. Due to the iliac crest being non–weight iliac crest has some unique advantages compared with other
bearing, density and flow resistance are relatively low. This sites, such as site availability, potentially better flow rate, ease
suggests flow rates would be similar to sternal IO flow rates. of insertion, and workspace utilization.
More devoted studies would be required to confirm this. Cer-
tainly, tibial access consistently lags regarding this metric. Conclusion
This is the first report of a whole blood transfusion through an
Anatomic differences among the possible sites are important to iliac crest IO for hemorrhagic shock in a military prehospital
consider. The iliac crest has a relatively wide medullary cavity setting. Based on our experience, the possibility of needing to
and is deep considering the trajectory of IO placement, mak- care for triple and quadruple amputees, as well as the favor-
ing this site relatively straightforward (Figure 1). Compara- able anatomic attributes of the iliac crest, makes the iliac crest
tively, the medullary cavity of the sternum is shallower when IO an important contingency in polytrauma patients when ex-
approached perpendicular to the cortex. Lack of a distinct tremity and sternal access are not available.
bony prominence and the spherical surface of the humeral
head make identifying this site more difficult. Additionally,
extremity IO sites could be difficult to access in an agitated References
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92 | JSOM Volume 21, Edition 4 / Winter 2021