# SVT: Unable to obtain IV...IO?



## Hockey (Jan 17, 2012)

Was just reading random articles and found this one that appears to be from 1994

http://archpedi.ama-assn.org/cgi/content/abstract/148/6/616

Lets say you're unable to get an IV on a stable patient with SVT.  

Can you go IO and actually have Adenosine still work just as good?


----------



## 18G (Jan 17, 2012)

If patient is stable with SVT I would probably not go with IO if transport time is short. If VTACH, than yeah I would go IO to treat that. 

You pose a good question though regarding IO adenosine. Thanks for the link!


----------



## Fish (Jan 17, 2012)

Good question, I have never had the situation arise


----------



## Hockey (Jan 17, 2012)

Whew.  It took me 3 days to get the courage to post this.  All I could think is I'm going to get flamed and get asked "and you're a Paramedic?!?!" :lol:

IV's make me nervous as a new medic.  Why?  Because in the back of my head I think...if I can't get an IV on this terrible call and for some reason, IO won't happen...


----------



## Fish (Jan 17, 2012)

Hockey said:


> Whew.  It took me 3 days to get the courage to post this.  All I could think is I'm going to get flamed and get asked "and you're a Paramedic?!?!" :lol:
> 
> IV's make me nervous as a new medic.  Why?  Because in the back of my head I think...if I can't get an IV on this terrible call and for some reason, IO won't happen...



No Vagal, No IV, No IO. Cardiovert


----------



## NYMedic828 (Jan 17, 2012)

If i had an SVT and couldn't get an IV, assuming they are hemodynamically stable just txp...

If the patient truly is having severe symptoms or is unconscious than the definitive care is the same, cardioversion. (except for possible long standing a-fib >48 hours)

If the patient isn't conscious, thats why we have things like versed or ativan which we can give IM or IN to sedate them for cardioversion.

Adenosine doesn't work on many patients. Sometimes you will end up sedating and cardioverting regardless if the situation calls for immediate care.

Also, IO adenosine may pose the problem of losing the potency of the drug by the time it reaches the myocardium. You should be performing an immediate flush of 20ccs on a regular IV to get it into circulation asap. If it comes all the way from the lower extremities and isn't direct into a vein it may not work?


----------



## CANMAN (Jan 17, 2012)

The half-life of adenosine is 10 seconds and is cleared from the plasma in under 30 seconds. With that being said I would highly doubt you would see effects dramatic enough to convert someone with legit svt even with a large fast flush. Stable svt I would monitor, unstable sedate as stated and cardiovert.


----------



## Aidey (Jan 18, 2012)

IO adenosine should work, especially in a humeral head IO. Watch some videos on how fast IO contrast dye is absorbed into the system, there really isn't a delay.


----------



## exodus (Jan 18, 2012)

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


----------



## DPM (Jan 18, 2012)

NYMedic828 said:


> Also, IO adenosine may pose the problem of losing the potency of the drug by the time it reaches the myocardium. You should be performing an immediate flush of 20ccs on a regular IV to get it into circulation asap. If it comes all the way from the lower extremities and isn't direct into a vein it may not work?



Granted the research used Pigs and not humans, but they found that the dose required was less than with a peripheral IV, which would support the theory that it should work better than an IV.

Either way, if you cannot gain access then Versed and cardioversion is the answer.


----------



## Simusid (Jan 18, 2012)

I've got an IO question but probably not worthy of its own post, so I'll just tag along here.   Are there drugs that can be pushed by IV but not by IO?


----------



## NYMedic828 (Jan 18, 2012)

Simusid said:


> I've got an IO question but probably not worthy of its own post, so I'll just tag along here.   Are there drugs that can be pushed by IV but not by IO?



I can't see why there would be but I don't know for sure.

The osseous tissue is extremely rich in blood supply and circulation the only thing I have come to notice in my short time as a medic is that it is much harder to push drugs into, and you cannot gravity drip meds into it. You need some form of pressure behind the bag. 

I imagine it has to do with the fact that you are kind of pushing through a network of spongy material with less elasticity than that of a vein, which would just be an open pipe with a more constant flow of blood in it. Pushing d50 through an IO is a chore.

The only thing questionable for me with adenosine IO is that in NYC I can only do a tibial IO, which puts the entrance site for the meds twice as far from the myocardium it needs to act on.


----------



## systemet (Jan 18, 2012)

NYMedic828 said:


> Pushing d50 through an IO is a chore.





!?


----------



## NYMedic828 (Jan 18, 2012)

systemet said:


> !?



What? (it was for asystolic cardiac arrest...:blush


----------



## Jon (Jan 18, 2012)

Alright. Initial article was re: pediatrics. I've seen tibial IO adenosine work in infants.

Now, many of us are using IO's as a second-line vascular access option for ALL patients. I've been told that a humeral head IO has acceptable time to central circulation to be used with adenosine - and I know at least one "supermedic" who's done it successfully.


----------



## Jon (Jan 18, 2012)

NYMedic828 said:


> What? (it was for asystolic cardiac arrest...:blush



Was the patient diabetic? Did you have a hypoglycemic blood sugar reading?


----------



## MedicBender (Jan 18, 2012)

Simusid said:


> I've got an IO question but probably not worthy of its own post, so I'll just tag along here.   Are there drugs that can be pushed by IV but not by IO?



All of our drugs carried by ALS can be infused via IO. Big exceptions I know of are only in the hospital setting. Chemotherapy is the big one that comes to mind. I'll see if I can find a reference for this. If anyone knows better please correct me. 

D50 is a PIA but it can be done.


----------



## Ramis46 (Jan 18, 2012)

If the Pt is stable SVT and you have tried the Vagel manuvers, and you are thinking of Cardioversion then you need some kinda of access. In our service you can't do any type of invasive procedure without IV access. If Pt is stable enough transport without IV. Have O2, and monitor (12-lead obtained for sure). If Unstable then really do you have a Choice? EZ-IO is awesome and pretty easy to access.


----------



## STXmedic (Jan 18, 2012)

Ramis46 said:


> If the Pt is stable SVT and you have tried the Vagel manuvers, and you are thinking of Cardioversion then you need some kinda of access.



If they're stable, why would you be thinking of cardioversion? Just transport. If they're unstable, sure drill them but they're getting cardioversion with access or not. If you have it available and it's tolerable, midazolam IN or diazepam IM would likely be appreciated by the patient as well.


----------



## 46Young (Jan 18, 2012)

I've cardioverted into asystole before, so I'd like to have some sort of access before I start electrical therapy. 

I've chemically converted several people on the first round of 12 after having them tell me that the adenosine didn't work. With a Hx of known failuire to chemically cardiovert, I'll go with a 16G instead of an 18G, and do the standard 20cc rapid flush. I'm also not opposed to getting an EJ for the SVT pt; I've done it quite a few times on the CHF/APE.

If nothing else, I'd do the IO prior to cardioversion. The painful part is not the drilling, it's the infusion afterwards, so don't forget to admin lido at the site if they're conscious. You'll need access for arrest meds if you kill them by cardioversion. I would have the tube kit out, and the arrest meds at the ready before I cardiovert, just in case.


----------



## Shishkabob (Jan 18, 2012)

Stable SVT without access?  Try a vagal then go to the hospital.


Unstable SVT without access?  Make access.  Still no access?  Shock.  It's unstable.


----------



## NYMedic828 (Jan 18, 2012)

Jon said:


> Was the patient diabetic? Did you have a hypoglycemic blood sugar reading?



Only did it once. I was a student on rotation and the medics i was with simply ran the cookbook of the protocol. The patient was a diabetic but they never took a glucose reading. But for the sake of the thread, it was an epic PIA to push d50 through an IO.

Now I know better, and don't do it unless there is reason to be pushing d50.


----------



## 46Young (Jan 18, 2012)

NYMedic828 said:


> Only did it once. I was a student on rotation and the medics i was with simply ran the cookbook of the protocol. The patient was a diabetic but they never took a glucose reading. But for the sake of the thread, it was an epic PIA to push d50 through an IO.
> 
> Now I know better, and don't do it unless there is reason to be pushing d50.



I know what you mean. In the NYC 911 system, glucometers weren't mandatory, just like CPAP isn't mandatory. I never took a BGL until I left the state. It was stupid in that we had to give D50 for the AMS, even if the pt's BGL was taken PTA with their own glucometer which was showing high. If we didn't it would be breaking protocol, even though we knew better. I've been a medic long enough to have used the unresponsive cocktail: D50, thiamine and narcan. You're pushing all this stuff because you have to, knowing that it isn't going to be of any benefit.


----------



## NYMedic828 (Jan 18, 2012)

46Young said:


> I know what you mean. In the NYC 911 system, glucometers weren't mandatory, just like CPAP isn't mandatory. I never took a BGL until I left the state. It was stupid in that we had to give D50 for the AMS, even if the pt's BGL was taken PTA with their own glucometer which was showing high. If we didn't it would be breaking protocol, even though we knew better. I've been a medic long enough to have used the unresponsive cocktail: D50, thiamine and narcan. You're pushing all this stuff because you have to, knowing that it isn't going to be of any benefit.



A glucometer is certainly an ALS requirement in NYC...

It isnt required to get a sugar reading on an arrest.


----------



## Fish (Jan 18, 2012)

NYMedic828 said:


> A glucometer is certainly an ALS requirement in NYC...
> 
> It isnt required to get a sugar reading on an arrest.



Weird


----------



## Scott33 (Jan 19, 2012)

NYMedic828 said:


> A glucometer is certainly an ALS requirement in NYC...



I am not sure if that is the case, or if it is more an agency-specific thing. Certainly the wording of the current MAC protocols would suggest that glucometry is still optional - _"A glucometer (if available) may be used to document blood glucose level prior to Dextrose administration"_.


----------



## NYMedic828 (Jan 19, 2012)

Scott33 said:


> I am not sure if that is the case, or if it is more an agency-specific thing. Certainly the wording of the current MAC protocols would suggest that glucometry is still optional - _"A glucometer (if available) may be used to document blood glucose level prior to Dextrose administration"_.



You actually raise a good point there. That is strange...

I don't know anyone though that would be willing to administer dextrose to an AMS patient without checking blood glucose. I have never in my 3 years with the city encountered a unit that did not carry a glucometer.

CPAP equipped units on the other hand is rare, but lets stay on topic in this thread.


----------



## MSDeltaFlt (Jan 19, 2012)

When one is talking about the critical status of his/her pt with regards to vascular access, or even the lack thereof, one must also define to what extent he/she is unable to gain vascular access.  In this hypothetical situation, was the EJ assessed?  Was the hepatojugar reflux assessed?  Was the pt instructed to swallow to engorge EJ?  

One must also use critical thinking skills.  Though IO is available for administration of adenosine, the distanceis key.  ACLS/protocols (most/mine anyway) dictate a PROXYMAL vascular site no further from the heart than the AC.  Unless you are able to establish an IO in the humeral head, Then IO in not practical for adenosine.

However, it is feasible to improve proxymal vascular access with IO by giving fluid boluses.  Just make sure breath sounds are able to tolerate the boluses.


----------



## cruiseforever (Jan 19, 2012)

I had success giving Adenosine with a 22 ga. IV in a foot.  My partner and I thought it was a long shot but gave it a try and it worked.  I did have a syringe of saline in the port above the port for Adenosine.  I pushed the Adenosine and my partner pushed the saline at teh same time.


----------



## Veneficus (Jan 19, 2012)

I vote for:

If stable, drive calmly to hospital.

If unstable, pull out all stops, but I would probably start with electricity if they were bad.


----------



## 46Young (Jan 19, 2012)

NYMedic828 said:


> A glucometer is certainly an ALS requirement in NYC...
> 
> It isnt required to get a sugar reading on an arrest.



It wasn't required when I last worked in the system back in Oct. 2007.


----------



## 46Young (Jan 19, 2012)

Scott33 said:


> I am not sure if that is the case, or if it is more an agency-specific thing. Certainly the wording of the current MAC protocols would suggest that glucometry is still optional - _"A glucometer (if available) may be used to document blood glucose level prior to Dextrose administration"_.



That's how I remember the MAC. I think that the Redimedics field guide said the same thing.


----------



## Ramis46 (Jan 19, 2012)

PoeticInjustice said:


> If they're stable, why would you be thinking of cardioversion?


Sorry that was kind of a run on thought of 2 things, didn't proof read my self very well.


----------

