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Editor,—Further to Foëx's historical note on the intraosseous route for fluid administration1 and Lavis's recommendations regarding its use in extreme circumstances in adults,2 we would like to mention our previously reported experience where use of an intracalcaneal infusion proved very successful in the resuscitation of a seriously ill child.3 In our opinion, this case questions the assumption that it is necessary to have a functioning medullary cavity in the bone where an intraosseous needle is used. Could it just be that a bone is a well defined container that provides an easier target than a vein for a needle in the haemodynamically shutdown patient, and that once the intraosseous pressure is increased by fluid infusion, the pressure is lowered by squeezing the fluid into the circulation via emissary veins?
Many haemodynamically shutdown trauma patients are at high risk of having sustained major pelvic trauma. This reduces the certainty of access to an intact venous circulation via lower limb or pelvic intraosseous routes. If it were to be shown to be the case that penetration of bones other than those with functioning medullary cavities facilitates fluid resuscitation, it raises the possibility of using relatively easily accessible proximal sites, such as the radial styloid or greater tuberosity, in extreme circumstances—more research needed?
The author's reply
McCarthy and Buss raise an interesting point. The essential premise for intraosseous infusion is a functioning medullary cavity. Tocantins et al commented “In infants under 3 years of age the marrow cavity of the sternum is not large enough to permit its use for the purpose.”1 They also described an adult patient in whom the intramedullary infusion was unsuccessful. At necropsy the sternal marrow was found to be unusually dense. To them an adequate medullary cavity appeared essential. The experience of McCarthy and Buss with an intracalcaneal route suggested otherwise.2
The problem of an intact venous circulation from the lower limb after a significant pelvic injury may necessitate use of the upper limb. Tocantins and O'Neill investigated the use of the humerus. In one of their 1941 papers they included a photograph of a newborn infant in whom mercury was injected into the lower humeri (and upper ends of the tibias).3 This clearly shows the metal passing through the emissary veins and into the general circulation. The humerus would seem to be an alternative to the upper tibia or lower femur.
While the radial styloid is very accessible and safe, and may yet prove to be effective, if the circumstances are so extreme why not use the proven sternal route? If alternative sites are to be used the more research is needed.