Paucis Verbis card: Interpretation of intraosseous blood

IO needles intraosseous labs

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?

In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.

Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.

PV Card: Interpreting Labs from the IO Line

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Michael McGonigal at Trauma Professional’s Blog for posting about this.


  1. Miller L, Philbeck T, Montez D, Spadaccini C. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. [PubMed]
By |2021-10-11T15:23:29-07:00Jan 13, 2012|ALiEM Cards, Heme-Oncology|

Paucis Verbis: Neutropenic fever in cancer patients

ThermometerA 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:

  • Temperature 39 C
  • BP 160/80
  • HR 60
  • RR 14
  • Oxygen saturation 99% on room air

His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.

  • Is this patient “high” or “low” risk per the Multinational Association for Supportive Care in Cancer (MASCC)?
  • Does this person require inpatient admission?
  • What antibiotics would you start on this patient?


  • The patient’s MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
  • NOTE: “Burden of febrile neutropenia” is a subjective scoring of the patient’s symptoms
  • The patient is, however, ultimately HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
  • Abx = Cefipime + Vancomycin

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

PV Card: Neutropenic Fever in Cancer Patients (IDSA 2010)

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Alissa and Hemal for suggesting the topic!


  1. Freifeld A, Bow E, Sepkowitz K, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011;52(4):e56-93. [PubMed]
By |2021-10-12T15:54:10-07:00Oct 7, 2011|ALiEM Cards, Heme-Oncology, Infectious Disease|

Paucis Verbis card: Supratherapeutic INR

What do you do in these cases?

  • A man on coumadin for atrial fibrillation arrives because he has increased bruising on his skin. He is otherwise asymptomatic. He was told to come to the ED because of a lab result showing INR = 6.
  • A woman on coumadin for atrial fibrillation arrives because of melena and hematemesis. She looks extremely sheet-white pale. Her vital signs are surprising normal. Stat labs show a hematocrit of 15 and an INR value that the lab is “unable to calculate” because it is so high.

Updated on 6/1/13: Old PV card revised to reflect the 2012 ACCP guidelines


By |2017-03-05T14:14:35-08:00Jan 15, 2010|ALiEM Cards, Heme-Oncology, Tox & Medications|
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