# EZ-IO vs IV



## ExpatMedic0 (Jun 25, 2010)

The EZ-IO is a new tool for me. We do not even use IV's anymore for codes. The manufacture propaganda really makes it appear to be as invasive as an IV maybe even less. So here is my question, I would like some thoughts and feed back from people on using the easy IO vs an IV. Especially those of you who have had experience with it.

Is the risk of infection greater than a pre-hospital IV start?

Do you think an EZ IO is an appropriate substitute for an IV in non life threating situations? For example: The administration of analgesics due to difficult venous access or other reasons venous access is not an easy option.

Or, how about for fluid replacement in a TSE?


 Ive seen a GCS15 volunteer take one. She said it hurt less than an IV start. Ive also seen several training videos of RN's giving them to each other for training. 
Please see below video of doctors doing it on each other. 

http://www.youtube.com/watch?v=3pZxOqfB3YA


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## Shishkabob (Jun 25, 2010)

I used an EZ-IO in my one and only cardiac arrest... loved it.  Pop in, pop out, screw on the line, and meds are being pushed in ASAP.     In all the videos I've seen of conscious patient they say it hurts less than an IV.



Cant say for sure, but does the bone marrow have less circulating WBCs than the venous system?




However, I think IOs should be reserved for life threatening immediate access.  You can ruin someones bone growth doing an IO, and if they aren't dying, they might not appreciate having one limb shorter than the other.


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## ExpatMedic0 (Jun 25, 2010)

Linus, are you talking only in children? The risk of accidental damage to the epiphyseal plate?


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## Smash (Jun 25, 2010)

There are risks to the growth plate if you place the IO too proximal in children, but so long as you locate it appropriately there shouldn't be any major issues.

It can to be used in patients who are not in cardiac arrest or immediate life threat.  I don't know what TSE means, so I can't say how appropriate or not it is.  It _could_ certainly be used for someone who needs analgesia in whom you cannot obtain IV access (depending on the situation: I wouldn't go whacking in an IO for every little old lady with a fractured neck of femur)

The only concern I have personally (and it may not be anything other than my vague paranoia) is that it is taking the place of appropriate IV access rather than being used as a back-up or alternative where IV access is impossible.  There are very, very few occassions that I can recall when I have been unable to obtain any kind of IV access, even if it is a 24g in an adult.  In those situations though, I am happy to use IO.


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## 1badassEMT-I (Jun 25, 2010)

schulz said:


> Do you think an EZ IO is an appropriate substitute for an IV in non life threating situations? For example: The administration of analgesics due to difficult venous access or other reasons venous access is not an easy option.



Base on your question I would say no. Due to the cost of drill head and by the other  means of which you can administer an analgesic. And under our guidelines in my state they would allow me to use it in such a manner anyways. But I like the tool next best thing to buttered toast.


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## 82-Alpha599 (Jun 25, 2010)

you can always do IM analgesics.

How about a little Dextrose IO?  Haven't had to but I think I would, if BGL was LO and GCS 3.


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## Shishkabob (Jun 25, 2010)

Eh, give glucagon MAD or IM before you do an IO for hypoglycemia.


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## 8jimi8 (Jun 25, 2010)

I've seen an I filtrated phlebotic io.  In the two hospitals I've been employed at, a) io is gradually bring trained to er rns b) hospital policy is to remove an io within 24 hours of insertion… same as any field start.  My opinion is: io is an emergency tool with some appropriate appilcations.  For anyone who is willing to administer this treatment on a patient:  have you seen the pathology of bone infection which becomes resistant to antibiotics?


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## DrankTheKoolaid (Jun 25, 2010)

Linuss said:


> I used an EZ-IO in my one and only cardiac arrest... loved it.  Pop in, pop out, screw on the line, and meds are being pushed in ASAP.    * In all the videos I've seen of conscious patient they say it hurts less than an IV.*
> 
> 
> Cant say for sure, but does the bone marrow have less circulating WBCs than the venous system?
> ...






Dont believe the hype.   I had a cardiogenic shock patient not all that long ago that myself and the flight nurse couldnt get a IV on.  Drilled LLE and trust me he felt it and even as sick as he was did not appreciete it.


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## 1badassEMT-I (Jun 25, 2010)

Corky said:


> Dont believe the hype.   I had a cardiogenic shock patient not all that long ago that myself and the flight nurse couldnt get a IV on.  Drilled LLE and trust me he felt it and even as sick as he was did not appreciete it.



We had in service on it and the rep. said use all of the lidocaine in kit that they would feel it for sure.


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## NomadicMedic (Jun 25, 2010)

I'ved used the EZ-IO a few times and the patinet that lived told me it was the most painful thing she'd ever felt. (FWIW, She was in status seizure and when I pushed the flush she screamed and almost came off the stretcher... I think "ow" is the operative word here.)

However, in codes, it's the bees knees. I like having that rock solid access really quickly. I hear that many agencies are skipping right past a normal IV attempt and going straight to IO for codes. Makes sense to me. 

I'm a fan.


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## TransportJockey (Jun 25, 2010)

Never used the EZ-IO, just a normal manual bone needle and the BIG. Only for codes or patients that are CTD though.


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## medic417 (Jun 25, 2010)

Based on my experience patients say no pain until you push the lido.


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## Shishkabob (Jun 25, 2010)

Yeah... you can't really say that the pain they get from meds being pushed makes the IO more painful than an IV.


I had a shot in my stomach back in bootcamp.  The shot didn't hurt anymore than any other needle stick.  The meds hurt like hell and made my stomach cramp.




Still don't know what the shot was though... hmm, now that I'm in the medical field I should contact for my medical records, it'd be interesting to know what was done.


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## 8jimi8 (Jun 26, 2010)

if you don't know what it was, i'm betting it was something lame like experimental anthrax vaccine...


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## mycrofft (Jun 26, 2010)

*Hm. Does hypertonic material cause damage?*

Like D50?   Irritants like potassium or phenytoin might also cause local necrosis. Dunno.

Lidocaine hurts because it is busy firing and blocking neurons.


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## 8jimi8 (Jun 26, 2010)

well we certainly know that glucose damages the intima, so i'd posit a theory that it would also cause local irritations in other locations.





What I haven't seen that many people discussing...

Is everyone just tacitly agreeing that this is not the end all be all and shouldn't ever be a 1st line technique  (**excluding certain critical presentations**)??


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## LondonMedic (Jun 26, 2010)

8jimi8 said:


> Is everyone just tacitly agreeing that this is not the end all be all and shouldn't ever be a 1st line technique  (**excluding certain critical presentations**)??


That's certainly the line I would take, in fact I think that the costs, difficulties and risks should make it third or maybe fourth line.

That said, in this country it is third or fourth line and I've seen only a handful of these, all in pre-hospital arrests, where they _are_ useful but all had to be replaced with a better form of access shortly afterwards.


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## dmiracco (Jun 26, 2010)

That is correct, first line no excluding arrest and near arrest. 
The problems that I see is that the new or green medics use it as a crutch at times because its new and cool. I think the good ol IV attempt or even the easy with a fairly high successful EJ is going to the wayside for some medics cause they can drill.
The best practice for obtaining difficult IV's are in difficult situations, ie. arrest, hypoperfused patient. So how do you get better? I think we all can answer that question. 
Like many other tools we have to play with its a tool and dont get me wrong its a good tool in certain situations but without proper education/training and sometimes experience it can be problematic and painful. There is also variables in each patient as to the success of the IO placement.
Also dextrose can be utilized through an IO just not perferred and extreme caution should be used and this would be cirumstantial. There are other routes and meds ie. glucagon that could be used prior however it could be a way down the line option in extreme cases. 
Also the cost of a procedure or skill should never be the decision maker of if you should do something or not.


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## huey28 (Jun 26, 2010)

i have only used it in a burn pt and a few arrest... make sure you flush it good and use some lido if the are awake or you will have someone that wants to kill you


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## Veneficus (Jun 26, 2010)

8jimi8 said:


> well we certainly know that glucose damages the intima, so i'd posit a theory that it would also cause local irritations in other locations.
> 
> 
> 
> ...



this is a copy of my statement in the IM morphine thread prior to this thread being started in response to the original question of using an IO as an alternative route of administration of analgesia.

_"I think it depends on what your treatment goal is...

Are you willing to penetrate not only the skin and deep facial planes, but also bone in a non sterile environment which carries a real infection risk to deliver small doses of analgesia?

Don't forget that while in the emergent setting an IO is not a sterile procedure, in an ICU it is and for a valid reason. In some patients, just like prehospital or ED IV starts, nonsterile IOs are removed and sterile ones inserted.

Using morphine IM allows you to potentiate the effects of the drug by slowing the rate of absorbtion. I don't see why it would be a first line choice for any other reason.

I would look at you wierd if you stuck an IO in a patient to give relatively small doses of analgesics. I would think you seriously underestimate the risks of deep penetration of foreign bodies. I would also be somewhat concerned about your judgement as to what you think was a reasonable use of invasive procedures that were designed to be used in the most seriously ill patients in less critical populations." _


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## ExpatMedic0 (Jun 26, 2010)

Here are some hightlights from the manufacture.

_IO access has now become the preferred method of establishing vascular access for patients experiencing cardiac arrest, major trauma, airway compromise, along with patients who have poor peripheral vasculature such as diabetics, dialysis patients, burn victims, IV drug users, obese patients, dehydrated patients, and others. 

 Infections: Overall IO experience in thousands of children and adults show the infection rate to be less than 0.6 percent and those are usually not serious and can be treated as outpatients.1 The documented overall complication rate associated with intraosseous insertion and infusion is less than 1 percent.  Potential complications include extravasation (leakage), dislodgement of the needle, compartment syndrome, bone fracture, pain related to infusion of medications/fluids and infection._

I am not sure what the infection and complication statistics for pre hospital IV's are to compare.


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## Veneficus (Jun 26, 2010)

schulz said:


> Here are some hightlights from the manufacture.
> 
> _IO access has now become the *preferred method *of establishing vascular access for patients experiencing cardiac arrest, major trauma, airway compromise,* along with patients who have poor peripheral vasculature such as diabetics, dialysis patients, burn victims, IV drug users, obese patients, dehydrated patients, and others*._


_ 

I call BS on this. I would demand the names and locations of the facilities doing this. Then I would call them and ask under exactly what circumstances this is the case. I have not been to a hospital anywhere in the world where an IO is the preferred method of access in anything except the most critical of patients.



schulz said:



			Infections: Overall IO experience in thousands of children and adults show the infection rate to be less than 0.6 percent and those are usually not serious and can be treated as outpatients.1 The documented overall complication rate associated with intraosseous insertion and infusion is less than 1 percent.  Potential complications include extravasation (leakage), dislodgement of the needle, compartment syndrome, bone fracture, pain related to infusion of medications/fluids and infection.
		
Click to expand...

_


schulz said:


> I am not sure what the infection and complication statistics for pre hospital IV's are to compare.



Yea, but they forget to mention that medicare/medicade do not pay for the care of preventable adverse effects so the hospital eats the cost or it is transferred to the patient.

You should never base your treatments by the information (aka propaganda) put out by the manufacturer. They have a vestited interest to create experiments that are biased towards their product as well as suppress any evidence that demonstrates a negative.

The sad fact is it takes less time to create a poor product or procedure, get it approved, and sell it at tremendous profit then it does to recoup the damages it causes.

If you can't get an IV in the field, if the condition is not life threatening, let the hospital do it.

If it is the ability of the provider that is lacking, then that needs to be addressed, not a device invented to try and make up for it.

I was once told, when deciding what to do in the prehospital environment, the question that should always be asked is: "How is this going to look on the evening news."

But I have another gold standard now. "How about you let me perform that procedure on you or a loved one?"


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## LondonMedic (Jun 26, 2010)

Veneficus said:


> I was once told, when deciding what to do in the prehospital environment, the question that should always be asked is: "How is this going to look on the evening news."
> 
> But I have another gold standard now. "How about you let me perform that procedure on you or a loved one?"


I prefer the M'lud rule; can you explain and justify your actions in a sentence that starts with "M'lud".

I guess the Americanized version would involve the phrase "Your Honour".


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## Veneficus (Jun 26, 2010)

LondonMedic said:


> I prefer the M'lud rule; can you explain and justify your actions in a sentence that starts with "M'lud".
> 
> I guess the Americanized version would involve the phrase "Your Honour".



"Your Honour" would be preferred, it is a lot easier to justify actions to an educated mind.

The "jury of my peers" is what really scares me. In America my peers seem to be a bunch of high school graduates or less that couldn't figure out how to get excused from jury duty.

Britian seems like such a fantastic place.


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## usafmedic45 (Jun 26, 2010)

> You should never base your treatments by the information (aka propaganda) put out by the manufacturer. They have a vestited interest to create experiments that are biased towards their product as well as suppress any evidence that demonstrates a negative.



The only people less trustworthy than drug and medical product reps are malpractice/personal injury lawyers and the PR people for medical helicopter outfits.  Anything that comes out of the mouth of any of those groups should be considered to be more or less utterly false until you have independent evidence saying they are correct.


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## usafmedic45 (Jun 26, 2010)

> The "jury of my peers" is what really scares me. In America my peers seem to be a bunch of high school graduates or less that couldn't figure out how to get excused from jury duty.



You can always opt for a bench trial.


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## Veneficus (Jun 26, 2010)

usafmedic45 said:


> You can always opt for a bench trial.



Not in Ohio, anything over $20K must be decided by a jury.


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## jjesusfreak01 (Jun 26, 2010)

usafmedic45 said:


> The only people less trustworthy than drug and medical product reps are malpractice/personal injury lawyers and the *PR people for medical helicopter outfits*.



Hehe...I know this isn't directed at any particular jumpsuit wearing forum member...


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## Aidey (Jun 26, 2010)

We have 3 options available to use, peripheral IV, EJ, and EZ IO. If the patient is dead or nearly I may attempt one IV before I go to IO. If the pt isn't dead, I have to have a really really good reason to put in an IO. The more invasive a procedure, the more justification I need to perform it. 

What bugs me about the IO is that it has been touted as such a safe and side-effect free procedure people don't even hesitate to think about using it in anyone without thinking about complications. 

For example, I am very hesitant to use an IO in diabetics, dialysis patients, severe eating disorder patients, immunosuppressed/compromised patients etc. The reason is because of the risk of causing osteomyelitis or causing more damage to already severely damaged bones. If the patient is in cardiac arrest then that is the greater life threat, but if they aren't in arrest, it is harder to justify doing it. 

We have a protocol for IV access in dialysis patients, and it states that if the situation is emergent you can use their dialysis access. I would rather do that (and have) than use an IO.


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## usafmedic45 (Jun 26, 2010)

> Not in Ohio, anything over $20K must be decided by a jury.



Just another reason why I hate that state.


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## usafmedic45 (Jun 26, 2010)

> Hehe...I know this isn't directed at any particular jumpsuit wearing forum member...



Not sure who you're referring to (MrBrown?), but no, it was not aimed at anyone in particular.  I did have a particular service (AirEvac Lifeteam, or "Scare-Evac Deathteam: or "Death from Above" as they are not so jokingly called around aviation safety circles) in mind as an example but beyond that no, no one in particular in mind. 

BTW, I only have a problem with the way things are abused here in the US.  Most other countries have much better systems in place for utilization of aeromedical helicopters.


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## MrBrown (Jun 26, 2010)

"Brown I can't get an IV!"
"Damn it Oz, thats why your jumpsuit doesnt say DOCTOR on the back"
"Neither does yours, in fact yours is from when you went to jail for practising medicine without a license"

We used to have the BIG but withdrew it a few years ago and went back to the Cooks screw in needle because of a high failure rate.  

This year rollout started of the EZ IO for both adults and children who are severely unstable and require fluids or medicines where IV access is unable to be obtained.

Normally we place IVs in the forearm, hands, feet or EJ but the preference is moving away from EJs to an IO.  

Our Guidelines state we are able to place an IO in the distal humerus or proximal tibia only.  I had heard of a few people doing sternal IOs.

If your patient is critically sick and you can't get an IV into them then I don't see the problem with putting an IO.  I am wary of sparky people doing the black and decker treatment on anybody who has crappy veins however.

Best IO I've seen is a guy in a car wreck who got an IO in the humerus, knocked out with fentanyl and ketamine and intubated.

Needless to say that was by one of the helicopter doctors


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## Aidey (Jun 26, 2010)

MrBrown said:


> Our Guidelines state we are able to place an IO in the *distal humerus* or proximal tibia only.  I had heard of a few people doing sternal IOs.



Distal humerus? We can use the EZ IOs in the proximal tibia, proximal humerus (humeral head really), and distal tibia. I hadn't heard of the distal humerus though. 

I haven't heard of people using the EZ in the sternum, but there is an approved sternal IO, the FAST 1. I MUCH MUCH prefer the EZ IO! I like not having the IO right in the middle of things, plus the FAST 1 looks like a medieval torture device.


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## usafmedic45 (Jun 26, 2010)

> I hadn't heard of the distal humerus though.



I've heard of and seen it done in very muscular men where you otherwise could not get good access on the arm and the legs weren't viable options (multiple fractures, etc)


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## Veneficus (Jun 26, 2010)

it can be done on any long bone.

If you really want to be textbook, the bone should be producing red marrow. I have seen it on the illiac wings on kids too.


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## usafmedic45 (Jun 26, 2010)

> I have seen it on the illiac wings on kids too.



Ditto.  I've also seen distal femur and distal tibia used with various IO needles.


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## Aidey (Jun 27, 2010)

Illiac wings makes sense, since that is where bone marrow for donations is usually taken. It would stand to reason that if you can stick a needle in there and take something out that you can stick a needle in there and put something in. 

What are the landmarks for the distal humerus?


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## Melclin (Jun 27, 2010)

MrBrown said:


> "Brown I can't get an IV!"
> "Damn it Oz, thats why your jumpsuit doesnt say DOCTOR on the back"
> "Neither does yours, in fact yours is from when you went to jail for practising medicine without a license"



HAAAAA!  :lol:

You're a funny bugger. 

FYI, Doc Brown is referring to an abbreviation of my last name. Unfortunately, if I do ever do medicine or get a PhD, I will be *Dr. Oz* :wacko: I reckon I could host a ridiculous TV show with a name like that 


We are way behind the times for our IO stuff here. It is exists only at the second tier ALS (Intensive care) level and it is only for kids strictly speaking, as far as I know. We never discuss it at uni. Its just not on the radar mostly, although I have heard that some small groups are pushing for rolling it out to first tier ALS (basic level). I believe expense is the biggest issue.


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## ExpatMedic0 (Jun 27, 2010)

So.... Mr. Brown, an EZ-IO, an IV, and a Rabbi who is about to code99 , walk into a bar....


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## ExpatMedic0 (Jun 27, 2010)

Sorry, my joke was an epic fail.

Anyway... does anyone have any stats other than from the maker of EZ-IO to compare to pre-hospital IV stats?

I am curious. Some examples of things to compare would be, infections, success rates, time saved or lost and anything else.


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## jonmedic101 (Jun 27, 2010)

*intraosseous*

Hello.
as an Israeli Paramedic I can tell you that IO is almost completely like IV by all means.
i even heard of people that gave Adenosine through IO for PSVT and worked great!

the Driller devices is nice i have seen it in a confernce and know some people who are using it.
in Israel we prefer the Bone injection gun (BIG), as we find it much more suitable for pre-hospital setting. it is automatic, small and light (i can put 10 of them in my vest without feeling it) and works like a charme. also very good for mass casualty incidents (e.g. i can carry a lot of them in my vest and use without the need to assemble anything or the need of batteries).

it's always nice to hear that i am not the only one who uses more IO than IV in an emergency code....

Jonmedic101


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## Ridryder911 (Jun 29, 2010)

I did not read through all the posts, but was recently hired by Vidacare as a clinical educator. I have several hundred links and citations over I/O in compared studies. As of last month, there had only been one incidence of an infection that was r/t I/O insertion per the EZ I/O out of thousands of incidents. That one incident is even questionable. I discussed this over dinner with the physician that had that occurrence and she described it was a child already septic and had multiple organ failure syndromes prior to insertion; so even then a direct link r/t the I/O is questioned. 

The usage of I/O will and has became more favorable for several reasons. Decrease infection rate over traditional and central lines. Costs in comparison to central lines (kits-$200-400, x-ray, etc) and the simplicity of insertion. 

Most patients/families complaints of difficult IV's are the continuation of attempts, the pain involved, and then the post risks and side effects (phlebitis, DVT, infection, etc). The problem now is educating health care providers in advantages of using such a technique. Ironically, it was very popular in WWI as medics performed the procedure routinely but fell out of grace due to no prehospital care during that time frame and IV's were performed in strictly hospital settings.  

The I/O is a great alternative use for IV therapy. In resuscitation therapy efforts, where peripheral insertion is even difficult or will be time consuming, I/O is the best intervention. No resuscitation efforts can be adequately performed without an fluid and medication introduction. 

I attended the I/O Scientific Symposium last month in San Antonio. I was able to test the major I/O makers devices as well perform on animal and cadaver(s) different techniques. As well, noted repeated failure of the use of Epi being administered through the tracheal/bronchial route in comparison to the IV and I./O route. In fact, I/O humeral site was much faster than IV (average about 1.5 seconds from site to heart) per fluroscope observation. Very, very impressive. 

There are several good I/O kits, and needles. I have used all of them in clinical and animal studies. My personal bias of course is the EZ I/O due to the ease and ability to utilize. As well, continual studies is being conducted on other sites for insertion and time frame the I/O can be left in. ( FDA ruling prohibits other than tested sites and any device left in bone >24 is considered orthopedic) However; again new studies and attempts to change is happening. 

Vidacare is now introducing and emphasizing into the hospital arena. I believe you will see that this is one device that began in the prehospital setting and will be popular within the hospital community, as more practitioners learn of it. I know, I am teaching more and more physicians who love the idea of knowing that they will have a route available for them no matter of the patients condition. 

R/r 911


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## 8jimi8 (Jun 29, 2010)

Rid, are you advocating first line use of this technique over standard PIV access?  I know you didn't outright say that, but I am curious if this is where you are leaning towards.

I have witness first hand infiltration of  tibial plateau insertion site.  Funny because all of the nurses reporting off on it, didn't know what it was.  I took one look and could tell it was from an IO insertion.

a)  How long CAN it be left in?

b) Which patient's would you be advocating this technique for.  I can see looming problems with people trying to ambulate with an IO sticking out of their leg... connected to fluids... pushing a pole down the hall...  

nice to see you posting here again.  I figured you were no longer around!


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## ah2388 (Jul 1, 2010)

im guessing here, but I believe rid is advocating front line use of IO in most, if not all critical patients..

If that is the case I have to say that I agree, its easy as pie, requires less setup(albeit slight), and is safer than other methods.


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## ExpatMedic0 (Jul 1, 2010)

Just to some things up from what I have read on this thread.... Feel free to chime in or correct me if I am wrong.

Although not everyone seems to agree, most are advocating EZ-IO is an acceptable first line intervention during a cardiac arrest code instead of even trying an IV.

EZ-IO is also an acceptable 2nd line intervention in critical patients that require IV access for fluid or drugs and IV access is a problem ( although some prefer it as a last resort) 

In non critical patients things start to get fuzzy but....
when IV assess is difficult or not an option, EZ-IO maybe going overboard and other methods should be considered such as IM administration of analgesics, or just waiting until the patient is at the hospital. 

I would still be curious to compare prehospital IV-start infections and complications with EZ-IO start infections and complications. A long with any other side by side comparison of statistics.


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## ExpatMedic0 (Jul 1, 2010)

Also I am gathering the overall consensus is that EZ-IO is not considered something you can give "instead of an IV" or something that could replace IV treatment in the future (except in codes) but rather a secondary tool. The reason for this appears to be EZ-IO is considered a more invasive procedure vs in the IV.


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## Veneficus (Jul 2, 2010)

I read through this post and I don't remember seeing anyone suggest that an IO was not useful in a critical patient of anykind.

The OP was about whether or not it could be better than other routes for more stable patients.

Like any tool, it has benefits and drawbacks.

IO dialysis?

How about IO invasive monitoring?

Quicker than a central line for a critical patient or a code? Absolutely. A bit tougher to get a ABG or a Troponin out of it though.


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## usafmedic45 (Jul 2, 2010)

> A bit tougher to get a ABG



That's why people have carotids.


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## Veneficus (Jul 2, 2010)

usafmedic45 said:


> That's why people have carotids.



As with most medical procedures, I find that the highly skilled people do not seem to have a problem requiring another device anyway.


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## Aidey (Jul 2, 2010)

Veneficus said:


> IO dialysis?



I doubt it would work very well, at least with current dialysis technology. The exchange rate between the marrow and blood is probably too slow, the bone marrow cavity probably would hold enough fluid for it to work like peritoneal dialysis does. (Or were you listing examples of things that wouldn't work?) 

Rid (if you are still reading) what kind of studies have been done in patients with various types of bone disease? Have any issues come up with using them in any patient populations? (Dialysis, diabetes, osteoporosis etc).


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## ExpatMedic0 (Jul 2, 2010)

Veneficus said:


> I read through this post and I don't remember seeing anyone suggest that an IO was not useful in a critical patient of anykind.



I do not believe I claimed anyone made the statement it was "not useful in critical patients" I said some posters do not prefer it as a first or even second line intervention. (not talking about cardiac arrest)
 London said the below.

" in fact I think that the costs, difficulties and risks should make it third or maybe fourth line.

That said, in this country it is third or fourth line and I've seen only a handful of these, all in pre-hospital arrests, where they are useful but all had to be replaced with a better form of access shortly afterwards.


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## Veneficus (Jul 2, 2010)

Aidey said:


> I doubt it would work very well, at least with current dialysis technology. The exchange rate between the marrow and blood is probably too slow, the bone marrow cavity probably would hold enough fluid for it to work like peritoneal dialysis does. (Or were you listing examples of things that wouldn't work?)
> 
> Rid (if you are still reading) what kind of studies have been done in patients with various types of bone disease? Have any issues come up with using them in any patient populations? (Dialysis, diabetes, osteoporosis etc).



I was listing things that wouldn't work.


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## Fox800 (Jul 3, 2010)

schulz said:


> Ive seen a GCS15 volunteer take one. She said it hurt less than an IV start.



:unsure: Uh...wow. Sounds like someone needs to work on their IV skills!

I lub my EZ-IO. I can have it in place before teh firey finishes spiking the bag.


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## ExpatMedic0 (Jul 3, 2010)

Fox800 said:


> :unsure: Uh...wow. Sounds like someone needs to work on their IV skills!
> 
> I lub my EZ-IO. I can have it in place before teh firey finishes spiking the bag.



haha fox. But have you seen some of the videos? Paramedics, nurses and doctors doing them on each other. Most say it hurts less, youtube it.


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## MrBrown (Jul 3, 2010)

I hear the only painful part of IO access is administering the medications and/or fluids.

It seems the 2% lignocaine in my orange IV rollup has finally found a use; coz I ain't never seen it used pre-cannulation thats for darn sure! 

Would I go sticking an IO into a stable patient? No, .... but it would come in bloody handy for some shut down sepsis patient who had no veins or something like that.


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## Melbourne MICA (Jul 3, 2010)

*Interosseus*

IO is a last option if no IV sites can be found in our guidelines. We were about to get the EZIO but budget cuts have led to its substitution with a cheaper product.

I'm rather surprised to hear so many posters saying or implying an IO is a first line subtsitute for IV's even the preferred route for drug administration.

Infection through this route is diabolicaly dangerous. That's why (at least in our guidelines) pre-existing trauma or infection/contamination of the same limb is a contra-indication to IO placement.

I'll take the word of others that patients say it hurts less than an IV.

Personally I find it hard to believe. Just the thought of someone drilling a hole in my leg bone makes me cringe. 

EZIO is a good tool however provided the batteries are charged.

MM


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## MrBrown (Jul 3, 2010)

Melbourne MICA said:


> I'm rather surprised to hear so many posters saying or implying an IO is a first line subtsitute for IV's even the preferred route for drug administration.



I will agree that going round performing the Black and Deckerotomy on people who  are stable is inappropriate.

On the other hand if you have a shut down, severely sick patient who is unable to produce something viable to stick even a 20g into then I don't mind IOing them.

To paraphrase the great Frank Archer, does it mean we drill an IO into somebody because they need a bit of fluid or some morph and we can't be buggered to slip a drip into them? No.



Melbourne MICA said:


> Infection through this route is diabolicaly dangerous. That's why (at least in our guidelines) pre-existing trauma or infection/contamination of the same limb is a contra-indication to IO placement.



It's an absolute contraindication here



Melbourne MICA said:


> Personally I find it hard to believe. Just the thought of someone drilling a hole in my leg bone makes me cringe.



Thats what we have ketamine for ... do hand me that pack of D5


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## Melbourne MICA (Jul 3, 2010)

*Agreed*



MrBrown said:


> I will agree that going round performing the Black and Deckerotomy on people who  are stable is inappropriate.
> 
> On the other hand if you have a shut down, severely sick patient who is unable to produce something viable to stick even a 20g into then I don't mind IOing them.
> 
> ...



We're talking from the same page me thinks. Sick pts, typically unconscious though not necessarily so, shut down, kids or the very old with those awful  spidery veins that look like a relief map of the LA motorways. The last pt I IO'd had a gross head injury, needed to be RSI'd but as luck would have it had been bowled over carrying, you guessed it paint - skin coloured paint which happily applied itself to both her arms and torso. Anyway with not a vein in sitght it was bi-lateral tibial IO's - the first failed, the second OK. the last time I looked in ED a surgical reg was busily pumping fluids through the remaining IO line. A good option to have in a pinch.

We don't have ketamine in widespread use here as yet, morph, fentanyl the mainstays at present. Besides I wonder how much competencies with placing lines in difficult pts comes into this. The MICA guys here have a never say die attitude to getting that line in. Any peripheral spot - I've heard true stories of lines being put into temporal veins and even one in the penis!!!

The guys here have never looked at IO as anything beyond the point of last call.
How ever easy the much marketed technologies like EZIO may make it look, and yes I have used the device, you have the whole body basically to look for an IV line. Two tourniquets, go for the famliar spots first, forearms, cube fossaes, EJ's, lower limbs. There is always a line to be found somewhere before you need to start drilling holes in bone. Putting it that way to me makes it sound like it should be viewed. A SC vein versus a hole in a bone, the blood factory.

Big woosies. Harden up boys. Don't look for technologies to make it (apparently) easy, cause it aint never so despite what profit driven companies might tell you. When you have to do it, sure, give me a tool to maximise success rates with minimal complications. But at the end of the day if you can't find a line the pt is either significantly moribund or you just didn't look hard enough.

Besides if IO was the bees knees why are peripheral IV's the mainstay of practice across the entire spectrum of medicine?

If the JEMS website is anything to go by, the EMS market in the US is bombarded by companies wanting to save the  world with their wonder products and make bucket loads of cash whilst underestimating and downplaying or ignoring the nouse, skills and hands on abilities of the guys working the beat. Don't lose your clinical skills boys and girls for the sake of some piece of plastic and metal.

MM


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## Veneficus (Jul 3, 2010)

Melbourne MICA said:


> If the JEMS website is anything to go by, the EMS market in the US is bombarded by companies wanting to save the  world with their wonder products and make bucket loads of cash whilst underestimating and downplaying or ignoring the nouse, skills and hands on abilities of the guys working the beat. Don't lose your clinical skills boys and girls for the sake of some piece of plastic and metal.



"If you build a machine even an idiot can use, only an idiot will use it."

The idea that technology can be employed to make up for a substandard provider is alive and well. Look at many of the new ET gadgets. Every form of TV and fiber optic because people can't figure out how to put a tube in the correct hole.

Too bad reproduction wasn't that hard. The world would probably be a better place. 

EZ IO if you are too inept to start an IV.

How did we ever start IVs on hard sticks before? Oh yea, we practiced! Not to boast but I know providers who can start an IV on a patient who is a IV drug abusing, on chemo/radiation therapy, diabetic, dialysis patient who coded 10 minutes ago in under 90 seconds during a hurricane.

Can't stop bleeding? 

There's an app for that 

Why don't the marketing people just say it like it is:

"Since you absoultely suck at patient care and medicine, buy our product in order to fake it untill you can transfer care to somebody better."


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## Melbourne MICA (Jul 3, 2010)

*Getting your hnads dirty*



Veneficus said:


> "If you build a machine even an idiot can use, only an idiot will use it."
> 
> The idea that technology can be employed to make up for a substandard provider is alive and well. Look at many of the new ET gadgets. Every form of TV and fiber optic because people can't figure out how to put a tube in the correct hole.
> 
> ...



Well said venny. 

We had an observer on our MICA truck last week - a hospital trauma director from Kuala Lumpar, Malaysia no less. She had some very interesting perpsectives on her own doctors who worked in trauma telling us that more often than not their first port of call when assessing a patient was some piece of technology which more often than not didn't provide the answers they were seeking in the first place. Instead she told them, apply your clinical skills first and use the technologies as an adjunct to them. Their approach was arse about, she told us (not in those terms of course).

The salient piece of information was this mindset was most prevalent in the younger doctors who have grown with mobile phones, IPODS and computers.
She and her colleagues have now commenced a back to basics programme to install confidence in clinical skills and assessment methods. One of the main reasons for this was their approach was costing the hospital a small fortune.

All sounds mighty familiar doesn't it. 

We must all be mindful of treating techno solutions to clinical problems with some skepticism and caution. Many are extremely useful to be sure. EZIO is very good at what it does for example. However at the end of the day there are plenty of circumstances where such tools won't be an option and you will need to fall back on using your senses, your intuition, your experience and your skills.

MM


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## MrBrown (Jul 3, 2010)

Veneficus said:


> "Since you absoultely suck at patient care and medicine, buy our product in order to fake it untill you can transfer care to somebody better."



Finally! Somebody who understands my problem 

I wonder if whomever my registrar or consultant is in five years will notice?


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## mycrofft (Jul 9, 2010)

*Looks so easy*

 http://www.youtube.com/watch?v=uU7l6y92kgo
Pain level of 0 to 2, but pucker factor of 8/10.

What happens if you hook up a hypertonic or irritant solution like D50, K+, or phenytoin?

(RID, good to see your avatar again!)


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## i5adam8 (Jul 12, 2010)

Corky said:


> Dont believe the hype.   I had a cardiogenic shock patient not all that long ago that myself and the flight nurse couldnt get a IV on.  Drilled LLE and trust me he felt it and even as sick as he was did not appreciete it.



We actually have it in our protocols now to use a lidocain flush if we start an I.O.   Our department just got the EZ IO drills in about a year ago and it's only been used once, the biggest reason for this being we are a small department that only averages about 1-3 calls per day. And we have been really lucky (knock on wood) because our medics our pretty successful at getting an IV on patients.


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## Ridryder911 (Jul 12, 2010)

Veneficus said:


> "If you build a machine even an idiot can use, only an idiot will use it."
> 
> The idea that technology can be employed to make up for a substandard provider is alive and well. Look at many of the new ET gadgets. Every form of TV and fiber optic because people can't figure out how to put a tube in the correct hole.
> 
> ...



I agree upon points however; we also have to admit we have seen those that are determined that they can establish an IV .. no matter how many times it takes. 

Believe it or not; my emphasis is not teaching the product for EMS. That's a given thing.. is it simple, does it work... Yes  & yes. My emphasis is for those within the hospital setting. 

Peripheral IV is always and should be the "norm" but; the point is when one cannot perform the task one should look at alternative ways.. especially if it is easier and *more effective*. 

Let's take for example; if your child was severely dehydrated but the child is not in severe danger.. Many complaints of caregivers and patients is the repeated attempts causing pain and then delay in care ... as well the costs of repeated attempts... As studied, many much rather pay an additional fee than to go through such process... when a one time stick? Would that not make better sense? Should providers be competent in their skills .. you bet. *but * if there is another way that is easier on the patient .. Why not utilize it? Really, it is about the patient is it not? Majority of the treatment(s) cannot be performed without a line.. so, what is the problem. 

Should we become dependent on devices .. No but; let's not stick to a procedure strictly based upon tradition... 

R/r 911


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## Veneficus (Jul 12, 2010)

Ridryder911 said:


> I agree upon points however; we also have to admit we have seen those that are determined that they can establish an IV .. no matter how many times it takes.
> 
> Believe it or not; my emphasis is not teaching the product for EMS. That's a given thing.. is it simple, does it work... Yes  & yes. My emphasis is for those within the hospital setting.
> 
> ...



Rid,

I agree with what you are saying, I was trying to point out that many will use this as a crutch instead of sharpening the skills.

If I had to choose between sticking a patient with a needle 10+ times, doing a cutdown, or starting a central line or using an EZ IO, I would probably choose EZ IO because it is the least risky of all of that and as you said cuts down on the pain and psych trauma as well.

But I also don't want to see EMS providers or hospital providers reaching for the drill first in all but special circumstances because "it will be easier."


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## Melclin (Jul 12, 2010)

Rid,

Where does ultrasound guided cannulation fit into the equation?

Its is widely desired for difficult sticks in larger EDs around here. 

Surely it would be preferred OI in the hospital environment. 

As the population becomes fatter and technology becomes cheaper ($20 says in six months there is an iPhone app that allows you to perform an echo), would you consider it as preferable in EMS in the not to distant future, should hand held U/S become cheap enough.


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## Giddi (Jul 12, 2010)

While we´re at it, does anyone have experience with this.

http://accuvein.com/

Im wondering how well it works


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## 8jimi8 (Jul 12, 2010)

Giddi said:


> While we´re at it, does anyone have experience with this.
> 
> http://accuvein.com/
> 
> Im wondering how well it works



ive used it with about a 25% success rate over about 20 patients.  They were all hard to feel veins, no possibility of visualizing a vein.  

Now then we are talking about peripheral sticks here.  I know i could get an ej in seconds if i needed it, but on our floor, we are not allowed to stick anything but the arms, without a doctor's order.

the accuvein is terrible on fat people. it is also terrible if you have even anything more than scant arm hair.  Hair on the arm causes shadows in the red light, which in turn makes it impossible to visualize the veins.  i am not by any means a HAIRY guy and it is near impossible to see even the ROPES in my arms with that light because of the hair.  

and it is a huge and cumbersome device. i'd rather miss twice than go to another floor to get the device, knowing full well it will only work on the most hairless and thinnest of patients.


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## somePerson (Jul 12, 2010)

I loved the EZ-IO, on my internship I used it on every code that I knew we were going to pronounce anyway, even if I could get a line (my preceptor was all for trying rarely used skills on dead people). People are discussing the drawbacks of an IO, but isn't the whole point of using it as a last resort if you can't get a line anywhere on a critical patient? Pushing meds trough an IO is better than no meds.


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## Veneficus (Jul 12, 2010)

somePerson said:


> I loved the EZ-IO, on my internship I used it on every code that I knew we were going to pronounce anyway, even if I could get a line (my preceptor was all for trying rarely used skills on dead people). People are discussing the drawbacks of an IO, but isn't the whole point of using it as a last resort if you can't get a line anywhere on a critical patient? Pushing meds trough an IO is better than no meds.



The only thing I would like to point out is that those meds rarely work anyway.


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## MrBrown (Jul 12, 2010)

Veneficus said:


> The only thing I would like to point out is that those meds rarely work anyway.



I recall somebody saying that drugs in cardiac arrest don't work anyway ... and that was in 1993.


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## Ridryder911 (Jul 12, 2010)

We are in all agreement most med.'s in cardiac arrest are futile (generalization)   *but* until there are new research and other medications invented... we will have to use what we got. Now, with that saying truthfully we all have seen Epinephrine work as well as Atropine in isolated cases..otherwise: let's just call a hearse and be done with it! 

I don't sell I/O rather just teach for them for primarily emphasis for in hospital education and if the need be also for EMS. So increasing sales really does not affect me; but I much rather see and IO placed than a peripheral cut down performed (which is very timely, costly and high infection rate) for either a short term usage IV therapy or for any true emergency criteria. (in fact many physicians are no longer exposed to that skill). Nothing irritates me more than to see a resident that has acquired the "new skill" (central lines) or even an experienced Doc finally has that opportunity to place one in... and jumps on it! The costs of central lines is extreme (as well doubtful reimbursement will be paid with the new regulations), x-ray to confirm and not to even discuss the dangers to patients (pneumo's, embolism, etc) all in the sake of ... "I got to place one in".. ego's. The same as an EMS provider ensuring that their next patient meets their protocols to play with a new toy!...

IO's are *NOT* new. In fact was used very widely in WWI (per corpsman) and the one of the *few* reasons it was not continued was corpsman was not utilized in the civilian setting and hence IV's were started only at hospital settings. So this is not a new procedure or invention.. new methods .. yes but that is about all. I started my first IO on a SIDS in 1983 using a spinal needle.... so; really it's a non-debatable technique. 

Alike any tool or procedure... we need to emphasize the education behind using it. Alike most EMS skills, it is very, very simplistic.. it is the knowledge of therapy and intervention determines we are either we choose to be technicians or to become clinicians. 

R/r 911


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