# IO contraindications.



## Aidey (Dec 17, 2009)

In our protocols there are very few listed contraindications to IO. I've been thinking more lately about some disease processes and their affects on the body, and if we really want to IO those people. People with things like osteogenesis imperfecta, bone cancer, osteomyelitis, dwarfism (anatomy/growth plate differences). What about people with things like severely uncontrolled diabetes who have poor healing times or people with kidney disease who have poor bone density because of calcium leaching? 

So here are my questions, are any of these conditions contraindications for IO access in your system? What contraindications have you been taught? Should any of these be contraindications?


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## jgmedic (Dec 17, 2009)

None of those are absolute contraindications where I work, but mostly because IO is only prior to contact for critical peds and adult full arrest. conscious IO placement requires a base station order.


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## Dominion (Dec 17, 2009)

Copy Pasta from our protocols:

Everything in our protocols are standing orders except what is in the medics controlled drug kit.  

Indications
► Adult patients age ≥ 8 and/or 40 kg or greater
► Intravenous fluids or medications needed and a peripheral IV cannot be established AND exhibit 1 or more of the following:
 An altered mental status (GCS of 12 or less).
 Respiratory compromise (SaO2 80% after appropriate oxygen therapy, respiratory rate < 10 or > 40 per minute.
 Hemodynamic instability (Systolic BP of < 90).

Contraindications
► Fracture of the tibia or femur (consider alternate tibia)
► Previous orthopedic procedures (IO within 24 hours, Knee replacement) (consider alternate tibia)
 Pre-Existing medical condition (tumor near site or peripheral vascular disease).
 Infection at insertion site.
 Inability to locate landmarks due to significant edema.
 Excessive tissue at insertion site


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## vquintessence (Dec 17, 2009)

Dominion said:


> Copy Pasta from our protocols:
> 
> Everything in our protocols are standing orders except what is in the medics controlled drug kit.
> 
> ...



Eeek, those last two scare me!  Does your service not provide you guys with the LD size?


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## Aidey (Dec 18, 2009)

Even if you have the long needles you still can't do an IO if you don't have landmarks.

Do you guys think any of those listed conditions should be contraindications? Or any other conditions I didn't mention?


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## redcrossemt (Dec 18, 2009)

Aidey said:


> In our protocols there are very few listed contraindications to IO. I've been thinking more lately about some disease processes and their affects on the body, and if we really want to IO those people. People with things like osteogenesis imperfecta, bone cancer, osteomyelitis, dwarfism (anatomy/growth plate differences). What about people with things like severely uncontrolled diabetes who have poor healing times or people with kidney disease who have poor bone density because of calcium leaching?
> 
> So here are my questions, are any of these conditions contraindications for IO access in your system? What contraindications have you been taught? Should any of these be contraindications?



I was taught that osteogenesis imperfecta, bone cancer, and osteomyelitis were contraindications.

We didn't hear about kidney disease, dwarfism, etc. but it would be a clinical judgement call with any of these patients. When I'm to the point of IO access, it's typically a life or death situation and I've already decided peripheral access isn't going to happen.


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## atropine (Dec 18, 2009)

Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.


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## reaper (Dec 18, 2009)

FF mentality!


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## NomadicMedic (Dec 18, 2009)

atropine said:


> Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.



Oh yeah... I forgot. There's never any ROSC is Southern Cali.


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## boingo (Dec 18, 2009)

atropine said:


> Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.



Glad to hear that only corpses would be the recipient of those procedures on your watch.


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## redcrossemt (Dec 18, 2009)

atropine said:


> Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.



Yeah, and obtaining a patent IO in an unstable patient isn't important.


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## Dominion (Dec 18, 2009)

vquintessence said:


> Eeek, those last two scare me!  Does your service not provide you guys with the LD size?



My service only carries the shorter 'pediatric' versions.  For adults we have IV > EJ > Tube.  I'm extremely tired and I can't place LD.  What are you meaning by that?


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## Scott33 (Dec 18, 2009)

atropine said:


> Who cares if your using an IO, your patient is probably dead.



Still living in a box I see.

http://www.youtube.com/watch?v=uU7l6y92kgo


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## Aidey (Dec 19, 2009)

I'm not talking about "dead" patients, where the IO is the last ditch effort. I'm curious about patients who are likely to live but who need an intervention ASAP to keep it that way. Pre-hospital IO started out as a end of the line intervention, and I think a lot of us were taught that trauma to the bone or inability to palpate the landmarks were the only contraindications because the pt was likely in arrest anyway. Now that it is being used more in other types of patients, I'm wondering what other contraindications we need to be thinking about. 

What I would really like to do is find out if the EZ IO has been studied in anyone besides healthy people, and what they have found. 

In our protocols we are allowed to use IO in any "critical" patient that needs vascular access for medication or fluid administration. This includes hypoglycemic patients, anaphylaxis patients (if you need to RSI or give them fluids), anyone who qualifies for RSI and there is no IV, among others.


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## jonmedic101 (Dec 20, 2009)

*IO devices*

hey fellows,

what do you use for IO in your EMS?

jonmedic
Paramedic from the Israeli EMS


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## So. IL Medic (Dec 20, 2009)

Aidey said:


> What contraindications have you been taught? Should any of these be contraindications?



The only hard and fast contraindications we have is the universal fx at or above the IO site and infection, like cellulitis at the IO site. Caution with severe osteoporosis is included. 

Otherwise the greater concern is that if you are grabbing for your IO setup then the patient must require vascular access quickly so there are more immediate issues to worry about than calcification.

Moreover, more systems are expanding IO sites to include all "long bone" areas - tibia, illiac crest, sternum, humerus.


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## Aidey (Dec 20, 2009)

What I'm trying to work out is a "what is better" when you have a patient with no IV access, and you are forced to choose between an alternative access and IO, or no access at all. For example a dialysis patient, or someone with a PICC line for cancer treatment, or an indwelling sub-clavian cath. 

Obviously these are going to be rare situations, which is why I think we don't really discuss them when addressing IO access. In an OI patient they may not have a fracture of the long bone now, but inserting the IO could cause one. 

Say you have a 40 year hypoglycemic patient with known Type 1 diabetes that has been very poorly controlled. She is unresponsive and currently reading "low" on the glucometer. The pt has a history of going into cardiac arrest 3 times this year secondary to hypoglycemia because vascular access is so difficult on her. The pt is mostly blind, has a L AKA post osteomyelitis a couple of years ago and has been on dialysis for the last several years. The pt also tends to be non-compliant with her renal diet. 

This is a patient who doesn't heal well, likely has osteoperosis, or decreased bone density, a history of amputation from a bone infection and is really not someone you want to wait to give sugar too because of her history to go down fast. What is better, sticking her fistula or giving her an IO?


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## redcrossemt (Dec 20, 2009)

Aidey said:


> This is a patient who doesn't heal well, likely has osteoperosis, or decreased bone density, a history of amputation from a bone infection and is really not someone you want to wait to give sugar too because of her history to go down fast. What is better, sticking her fistula or giving her an IO?



Wow... Uhm... That's no good. I guess I would try a couple sticks at peripheral access including looking for an EJ, and then go to IO and be careful about cleanliness. Sticking a fistula is always a bad thing... This patient's fistula going bad would be very detrimental to her outcome.


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## Aidey (Dec 20, 2009)

Why do you say sticking a fistula (or graft) always a bad thing? 

Obviously, if you mess it up it is a bad thing, but it's designed to be stuck by needles.


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## redcrossemt (Dec 20, 2009)

Aidey said:


> Why do you say sticking a fistula (or graft) always a bad thing?
> 
> Obviously, if you mess it up it is a bad thing, but it's designed to be stuck by needles.



Never say always, right?

I think it's something that we can look to as a last resort, but something that should never be taken lightly. The complications of an infection or mess up can be devastating to the patient, requiring placement of a temporary dialysis catheter (and changes of that), while they try to get another fistula to take (which can take many months - if they can even do another one). These are typically accessed in much cleaner and controlled conditions than we have to work with. Remember, the patient may die without dialysis access. 

At the same level, you have to weigh the risk factors of the fistula versus the risks of the other access (IO), and compare these to the benefits of access in your patient. I think I would personally attempt IO first, but would go on to the fistula (with medical control orders in my system) if the patient was critical.


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## Aidey (Dec 20, 2009)

I used to work as a dialysis tech, so I have a bit of an insiders view on the whole thing. Honestly, if we are doing IVs properly in the field, it isn't much different than accessing a fistula in an outpatient dialysis clinic. The biggest difference is the amount of PPE the dialysis techs wear, which includes a face shield and disposable lab coat. 

I personally am more apt to go fistula (or catheter, or Picc line) before IO in a chronically ill patient. If some sort of vascular access is already present, I'm not really sure I want to go sticking a needle into someone's bone. If something goes wrong, the first words out of the lawyer's mouth in trial will be "Why did you do this when you already had a route of vascular access".

I've spent the last 2 days trying to find EZ IO studies done on patients with pre-existing conditions, like diabetes, or kidney failure, or different degrees of osteoperosis and I can't find a single one. All the ones I've found don't specify what the participant's underlying health status was.


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## So. IL Medic (Dec 21, 2009)

Aidey said:


> Say you have a 40 year hypoglycemic patient with known Type 1 diabetes that has been very poorly controlled. She is unresponsive and currently reading "low" on the glucometer. The pt has a history of going into cardiac arrest 3 times this year secondary to hypoglycemia because vascular access is so difficult on her. The pt is mostly blind, has a L AKA post osteomyelitis a couple of years ago and has been on dialysis for the last several years. The pt also tends to be non-compliant with her renal diet.
> 
> This is a patient who doesn't heal well, likely has osteoperosis, or decreased bone density, a history of amputation from a bone infection and is really not someone you want to wait to give sugar too because of her history to go down fast. What is better, sticking her fistula or giving her an IO?



My first reaction was to admin glucagon IM while you debated to IO or not to IO....

Then if this hypothetical pt worsened towards arrest number four, then go with the IO. Any complications would be easier to treat than death.

Unfortunately around here, any attempt to access a fistula or graft would land you in the med director's office as we don't have the training for such access. Side note - we just got the system to consider port access training.


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## So. IL Medic (Dec 21, 2009)

Aidey said:


> If something goes wrong, the first words out of the lawyer's mouth in trial will be "Why did you do this when you already had a route of vascular access".



"Because our protocols don't allow accessing that route." Easy enough.


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## Aidey (Dec 21, 2009)

Our protocols do allow it if it is an "emergent" situation. If it wasn't allowed it would be that easy. 

For glucagon to work it requires the pt to have sufficient stores of glycogen, what are the chances a person that sick would have sufficient stores?


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## MissMedicCMO (Dec 27, 2009)

Dominion said:


> My service only carries the shorter 'pediatric' versions.  For adults we have IV > EJ > Tube.  I'm extremely tired and I can't place LD.  What are you meaning by that?



Thats all my service carries too.  They say they can be used on adults but not likely on a healthy adult.  I had a 15y/o/f, traumatic arrest who had no IV access what so ever...Attempted an IO 3 freakin times and everytime the needles bent..they are not designed for a stronger healthier bone.  I even checked with my ems director to make sure I wasn't doing something wrong..but he said no..they aren't meant to do adults really...and my fellow co-workers have had the same problems...

On that note..our protocols are pretty much the same as everyone elses as far as fx and edema...osto etc etc


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## So. IL Medic (Dec 28, 2009)

Aidey said:


> Our protocols do allow it if it is an "emergent" situation. If it wasn't allowed it would be that easy.
> 
> For glucagon to work it requires the pt to have sufficient stores of glycogen, what are the chances a person that sick would have sufficient stores?



True, glucagon stimulates glycogenolysis as it's primary action. However, two things to consider. One, it typically takes two to three days to deplete glycogen stores with normal activity enough for ketone metabolic pathways kick in as a supplement. Two, as glycogen stores deplete, pyruvate begins to be converted though a process similar to gluconeogenesis. Non-hepatic tissue lacks glucose-6-phosphatase and so the glucose-6-phosphate becomes a substrate for glycogen production. Essentially, it takes a long time to completely deplete glycogen stores.

If a patient had absolutely nothing p.o. for a couple of days, they would still have enough glycogen for some elevation of glucose but I would agree it's effectiveness would be decreased. Longer than that then there would be other issues to worry about.


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## Aidey (Dec 28, 2009)

What type of IO were you using?

That is in a healthy patient though, what about someone as sick as the hypothetical patient from above? Glucagon also takes time to work, what is to say the patient wont code in between administering it and waiting for it to kick in?


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## redcrossemt (Jan 4, 2010)

Aidey said:


> What type of IO were you using?



We use the Jamshidi and I've bent a few on adults... You have to be reeeeal slow with them.


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## Jeffrey_169 (Jan 5, 2010)

In Amarillo TX we have a drill type IO system, and there are so few contraindications because if a pt is that bad off and they need the infusion that badly, there are few things taking presidence over it. In our system if a pt. gets an IO they circling the drain and they despirately need it.


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## grich242 (Jan 5, 2010)

We use the BOne Injection Gun (B.I.G.) and it works great but placement is slightly modified and glucose while not "officialy" contraindicated but the 1 med discouraged via io unless its a last resort.


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## Aidey (Jan 5, 2010)

MissMedicCMO said:


> Thats all my service carries too.  They say they can be used on adults but not likely on a healthy adult.  I had a 15y/o/f, traumatic arrest who had no IV access what so ever...Attempted an IO 3 freakin times and everytime the needles bent..they are not designed for a stronger healthier bone.  I even checked with my ems director to make sure I wasn't doing something wrong..but he said no..they aren't meant to do adults really...and my fellow co-workers have had the same problems...
> 
> On that note..our protocols are pretty much the same as everyone elses as far as fx and edema...osto etc etc





redcrossemt said:


> We use the Jamshidi and I've bent a few on adults... You have to be reeeeal slow with them.



We have the EZ IO, so that isn't much of a concern.


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## redcrossemt (Jan 5, 2010)

Aidey said:


> We have the EZ IO, so that isn't much of a concern.



Yes, the EZ-IO, FAST, and BIG are all great access devices.


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## Aidey (Jan 6, 2010)

I'm not as fond of the FAST 1 as the others, mostly because it puts the IO up in the middle of all the action, rather than down in the leg. I like being able to get an IO and give all the drugs without getting in the way of people doing compressions or managing the airway.


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## jonmedic101 (Feb 25, 2010)

*B.i.g*

hey

I am an Israeli paramedic, and i am using the B.I.G repetedly for every situation i need an immidiate vascular access and don't have the time to search for veins.
i gave Glucose throgh the BIG several times. when i got my training for using the deivce from the manufactorer, i realized that we can give aNY medication throgh IO, including Glicose. if you dilute it to 25% as required there is no different that an IV. 
extravasation? if you penetrate in the appropriate location, this will never happen with the BIG, since the penetration is automatic and VERY fast- 0.something seconds. this may happen if you use the munal devices of the driller.
this is one of the reasons i prefer the BIG.

Jonmedic101


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## lightsandsirens5 (Feb 25, 2010)

redcrossemt said:


> We use the Jamshidi and I've bent a few on adults... You have to be reeeeal slow with them.


 
We use those too, but we should be switching to the drill pretty soon here.

~~~~~~~~~

From my state. EMS protocols:

II. Contraindications
A. Pt older than 6 yrs.
B. IO line should not be inserted if there is a known fx in the bone chosen for line placement
C. IO should not be placed in when there is an infection present in the leg chosen for placement. (Ie. Cellulites)
B. Do not attempt insertion twice in same limb.

County protocols:

Same as state, except we can use IOs on adults as well as infants and children. For critical children, we get 90 seconds to establish an IV line. If we cannot get in we go with the IO. For critical adults we get two or three tries on an IV, if we can't get that we do the IO.


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## FLEMTP (Feb 25, 2010)

Seems like most agencies have the same absolute contraindications.

We have the ability to use the IO however we see fit, conscious or not. Granted, inability to establish IV access in a patient is not a good reason to drill someone... we typically reserve it for critical patients..conscious or not. Conscious we have the ability to push lidocaine, which is the appropriate and humane thing to do... and versed should the need arise and the lidocaine isnt cutting it alone.

We also have the ability to place a central line (subclavian) should the need arise. It is no longer covered in our medical guidelines, but we also have the ability to do whatever we deem medically appropriate for the patient so long as we can justify it to the Medical Director after the fact. The frequency of a central line is very minimal now with the IO, but there are still patients who could and would be a candidate for one in the field...especially those with the contraindications to the IO

I also want to add this, because im sure some people will wonder about our term of the guidelines vs protocols and what we can and cannot do.

In our agency there is no reason for us to contact medical control at all. We are expected to have appropriate knowledge to treat the patients we see, and also the MD's in the ER really have no idea what we are capable of doing, or which medications or equipment we carry. I have on occasion, consulted a Doctor in the ER prior to providing certain treatments when a condition presents that I have limited knowledge in... but nothing says that I HAVE to follow any of the doctors orders if he tries to give me any, especially if I disagree with them. We work under the authority of our Medical Director, not the Doctor in the ED.


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## Flight-LP (Mar 6, 2010)

I'm surprised no one mentioned an AKA as being a contraindication. Seems it would be one if you are only authorized one insertion site............... 

The inability to located landmarks is a poor contraindication. The EZ I/O after all can be inserted in one of 3 locations and they make a longer needle for those grossly obese. I have yet to not be able to place one due to anatomy issue or excessive adipose tissue. It can be done, perhaps you should review current literature and trends in intraosseous care.


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