A severe complication following intraosseous infusion used during resuscitation of a child

Intramuscular hemorrhage and fluid extravasation into the anterior compartment secondary to intraosseous resuscitation, the “Nicked-Cortex” sign

“…Two case reports of IO induced osteomyelitis specifically describe the emergent use of adrenaline through the IO route, with one case using high doses (1:1000; 0.1 mg/kg) after the standard concentration of (1:10,000; 0.01 mg/kg) had little effect. Both of these cases reported a localize inflammatory response around the IO site that resulted in cutaneous necrosis as well as subsequent osteomyelitis [10], [18]. It could be theorized that multiple or high doses of IO adrenaline could elicit a local marrow infarct, thus predisposing one to osteomyelitis similar to the model described by Scheman.…”

“…IO associated extravasation of fluid into the soft tissues may result from “incomplete penetration of the needle through the cortical bone, extension of the cannula through the proximal tibia into the posterior compartment of the leg, extravasation through previous intraosseous puncture sites, and extravasation through the nutrient vessel foraminae [8].” IO access should be avoided in fractured extremities because of the risk of fluid extravasation [9]. In addition, secondary extravasation of fluid into the surrounding soft tissues can occur as a result of increased intraosseous pressure from a high rate of infusion or due to a large total volume infused [10].…”

“…Atanda et al described a case of compartment syndrome in a pediatric patient admitted for hemoperitoneum and pneumoperitoneum as a result of child abuse, requiring tibial IO access [9]. Similarly, Khan et al reported a case of compartment syndrome in an 11-year-old that needed emergency IO access due to spontaneous ventricular fibrillation [10].…”

Intraosseous vascular access: A review

“…With proximal tibial IO insertions, compartment syndrome usually occurs in the anterolateral compartment of the leg if it is due to leakage from around the insertion site, and in the posterior compartment following penetration of both cortices (Alam et al, 2002; Ribeiro et al, 1993). To date, compartment syndrome requiring fasciotomy following IO infusion has been reported in 16 cases (Rimar et al, 1988; Moscati and Moore, 1990; Galpin et al, 1991; Burke and Kehl, 1993; Ribeiro et al, 1993; Vidal et al, 1993; Wright et al, 1994; Gayle and Kissoon, 1994; Simmons et al, 1994; Launay et al, 2003; Moen and Sarwark, 2008; Taylor and Clarke, 2011; Khan et al, 2011). Of these 16 cases, 4 were shown to be due to needle dislodgement (Ribeiro et al, 1993; Wright et al, 1994; Launay et al, 2003; Taylor and Clarke, 2011) and 5 were associated with cortical fracture or multiple puncture attempts (Moscati and Moore, 1990; Burke and Kehl, 1993; Simmons et al, 1994; Taylor and Clarke, 2011).…”

“…Extensive tissue damage due to the subcutaneous extravasation of norepinephrine administered through a dislodged IO needle was described by Pillar (1954) as early as 1954. Since that time, many other cases of soft tissue or bony necrosis have been identified due to IO extravasation of high volumes of catecholamines or hypertonic solutions of saline, glucose and bicarbonate (Wallden and Lennart, 1947; Spivey, 1987; Christensen et al, 1991; Ellemunter, 1999; Alam et al, 2002; Khan et al, 2011). In at least two cases, such soft tissue injury has been associated with arterial thrombosis (Meola, 1944; Launay et al, 2003).…”