A dramatic case: fatal air embolism due to intraosseous puncture

Intraosseous access is a commonly used method for establishing vascular access in preclinical emergency care. It is often used when peripheral access cannot be established due to shock. Pressure infusions are used to overcome the resistance provided by the medullary cavity in order to achieve high flow rates needed for effective resuscitation. However, the literature to date does not seem to adequately describe the potential risks. In particular, air embolism is a potentially rare short-term fatal complication. We report on an elderly woman who lay comatose on the floor for at least six hours before she was found and given medical attention. In the emergency room, a CT scan showed large amounts of air in her venous system. This air came from an intraosseous line in her left tibia and entered the left pelvic vein, the ventral hepatic veins, the right ventricle and the pulmonary arteries. Despite all conservative measures, the patient died 18 hours later as a result of the air embolism. To date, there is no meaningful data in the literature on the use of pressure infusions via intraosseous access. The case described here highlights the risk of serious complications, which are probably underrepresented in the literature. There is an urgent need for self-reflection when dealing with this type of access and a necessity to develop clear guidelines regarding the inspection of connected systems and immediate emergency therapeutic measures. This case highlights the critical importance of careful use of intraosseous access, especially in situations with numerous other challenges that can cause distractions. Wherever possible, connection to the pressure device should be avoided rather than prescribed as an absolute requirement.