# Performing IO on conscious patients



## rhan101277 (Aug 14, 2011)

I had  pt the other day that was diaphoretic and complaining of only weakness with no pain.  Pt shirt is damp and arms are clammy.

Pt denies any medication, no previous medical history, is allergic to asa.

His initial vitals are

Pulse: 126 S. Tach w/ 1st degree block .266ms
BP: 136/82
Pulse ox: 94% room air
CBG: 116

He vomited twice in the past hour and hasn't had much food intake.

So in route I noticed a change in EKG to Afib @ 120's and it goes back and forth from Afib to S.Tach.  Pt blood pressure drops to 80/40, unable to get IV after 3 attempts.  After missing first attempt I put pt in trendelenburg position and after several minutes pressure rises to 122/84 and HR down to 81.  The patient remained AAOx3 but another blood pressure reading was 63/38, before trendelenburg.

Now there comes a point where I am going to need to start an IO, conscious be damned.  I have started some on cardiac arrest, but it bothers me to start one on someone who is alert.  We can use lidocaine to ease the pain of med admin but once IO is used it can lead to infection and such but that is better than a dead person.

I am thinking his cerebral perfusion pressure must have been adequate enough or else he would have been out.

Another worry is the ER being all grumbly.  He doesn't look that bad etc., whats a matter couldn't get a line.

Anyhow I just wanted to see how others have fared with IO's on alert patients with unstable vitals, which is clearly an indication for usage.


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## medicdan (Aug 14, 2011)

I'll offer a limited perspective. I've seen them put into conscious patients three times now-- once in training once in the ED and once in the field, and was amazed at how little pain the patient complained of. The actual insertion is just about painless, but discomfort comes with the first infusion of saline. What the Doc/Medic did was infuse lidocaine in the first saline flush, and it kept the line patent and pain-free. As discomfort returned several minutes later, they added a little more lidocaine. 

The three I've seen on conscious patients were EZ-IOs, but i've also seen several BIGs and wouldn't wish them on anyone resembling consciousness.


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## shfd739 (Aug 14, 2011)

A few years ago when we began using them they were inserviced during staff meetings. A few medics in each one volunteered to be drilled. Their responses ranged from no pain to railroad spike being driven thru their ankle. An initial push of lidocaine helped alot per all the ones that volunteered. 

Personally in this case with the BP coming back up I might hold off depending on proximity to the ER. This patient would be in a gray area of our conscious IO protocol. 


---
- Sent from my electronic overbearing life controller


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## MSDeltaFlt (Aug 14, 2011)

As you know, rhan, trendelenburg is only good for transient increases in BP.  If your pt is that shocky and conscious, you can't sedate so warn them that this is liable to hurt; especially when you flush the marrow open to allow for boluses.

However, when your battery gets low, THAT'S going to hurt like hell. Just saying.


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## Cawolf86 (Aug 15, 2011)

Here would generally go to an EJ before IO. A better option that is relatively easy to do (all IMO of course).


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## RocketMedic (Aug 15, 2011)

The EZIO isn't very painful, excepting the initial flush. The FAST1 is less fun.


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## 325Medic (Aug 17, 2011)

I just preformed 1 on a conscious pt. in shock / non-traumatic. Pt. had no b/p, no radial or carotid pulses and has been sick for 2 days with diahhrea. 3 attempts I.V. were unsuccessful including no obvious E.J. (bull neck). This is a first for me on a conscious pt. / I have preformed dozens on codes. Pt. felt minimal pain / lido given decreased what pain he was having. Thanks god for EZ-IO's. 

325.


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## MrBrown (Aug 17, 2011)

IO access is reserved for patients with a life threatening time critical need for medicine or fluid, conscious or not.

For years we used the Cooks screw in needle and have recently began to roll out the EZIO to regions as budgets allow for Intensive Care Paramedics, they are reasonably expensive and must be used wisely.

Should your bloke with AF be that crook then he should be cardioverted, whack some midaz up his snoz with the mucoosal atomiser, sure a line would be nicer but it is not essential.


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## systemet (Aug 17, 2011)

Just wondering how the patient turned out --- were they infarcting?


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## RocketMedic (Aug 17, 2011)

Ios are a fantastic tool. I'd rather have an IO than a mediocre or highly positional IV.
Our protocol is an IV or IO when judged nessasary.


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## jjesusfreak01 (Aug 17, 2011)

Cawolf86 said:


> Here would generally go to an EJ before IO. A better option that is relatively easy to do (all IMO of course).



Seeing as they had already dropped the patient into Trendelenburg, EJ would have seemed like a good choice too.


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## the_negro_puppy (Aug 17, 2011)

325Medic said:


> I just preformed 1 on a conscious pt. in shock / non-traumatic. Pt. had no b/p, no radial or carotid pulses and has been sick for 2 days with diahhrea. 3 attempts I.V. were unsuccessful including no obvious E.J. (bull neck). This is a first for me on a conscious pt. / I have preformed dozens on codes. Pt. felt minimal pain / lido given decreased what pain he was having. Thanks god for EZ-IO's.
> 
> 325.




Conscious but no carotid pulse?


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## 325Medic (Aug 17, 2011)

the_negro_puppy said:


> Conscious but no carotid pulse?



Amazing yes. Pt. was a 300+lb. male that was sitting naked on the toilet, diaphoretic, lethargic with no carotid / radial pulses / no palp. pressure, 12-lead was clean and sugar of 197... E.D. got a doppler pressure @ 60 per attending doc. 3 attempts for I.V. with no success, Lt. tib I.O. preformed and fluids in with pressure infuser. Still waiting to follow up with d/x.

325.


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## rhan101277 (Aug 18, 2011)

systemet said:


> Just wondering how the patient turned out --- were they infarcting?



No they were just very hypotensive and tachycardic.  He was dehydrated along with having frequent heart rhythm changes.  From Sinus tach to afib to sinus rhythm.  I am sure it was not helping his pre-load issues.


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## hyperlyeman1 (Aug 18, 2011)

Don't see what the issue is. Our goal is to improve patient outcome using whatever tools we have available and to use them when needed. Grab the gun and start drilling. If patient discomfort is your worry, lido is the answer, I don't know how your system works, but our protocol allows us to administer up to 50 mg (0.5 mg/kg) lido for any patient requiring an IO if they are conscious.


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## Jon (Aug 18, 2011)

I've never IO'd a conscious patient. No desire to inflict that pain on someone unless I REALLY REALLY REALLY need to. I've had 2 cases where I had the IO kit sitting next to me, watching vitals, and hoping that I didn't need to use it. I felt I was close enough to the ED to hold off unless something changed.


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## rhan101277 (Aug 19, 2011)

Jon said:


> I've never IO'd a conscious patient. No desire to inflict that pain on someone unless I REALLY REALLY REALLY need to. I've had 2 cases where I had the IO kit sitting next to me, watching vitals, and hoping that I didn't need to use it. I felt I was close enough to the ED to hold off unless something changed.



This is why I waited, and trendelenburg was helping.


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## RocketMedic (Aug 28, 2011)

Jon said:


> I've never IO'd a conscious patient. No desire to inflict that pain on someone unless I REALLY REALLY REALLY need to. I've had 2 cases where I had the IO kit sitting next to me, watching vitals, and hoping that I didn't need to use it. I felt I was close enough to the ED to hold off unless something changed.



Honestly, the IO really doesn't hurt- I found the EZ-IO into the right tibia (on me) less painful than a 14G AC stick. The drill makes it quick and relatively painless. I have no issues putting it into one of my patients if they need it. On a pediatric patient, I'd actually rather use it than poke them 3+ times with a standard IV catheter. 

The FAST-1, on the other hand, looks pretty painful, but accounts of medics who have taken it say that it's not that bad.


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## nmasi (Aug 29, 2011)

If they really, really needed the fluids so badly, why infuse through the IO?  Why not a subclavian at the er or a femoral?

Any word from the doc why they went that route?

Last time I saw an IO pressure infused, it was along with Ativan and Morphine since it was very uncomfortable.


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## usafmedic45 (Aug 29, 2011)

> Here would generally go to an EJ before IO. A better option that is relatively easy to do (all IMO of course).



:censored::censored::censored::censored: that.  I'd take an IO over an EJ or a subclavian while conscious any day.



> Why not a subclavian at the er or a femoral?


Speed and ease of insertion.  How many of each of those have you done?  An IO is a better choice if you've got a conscious patient (screw you, get away from my groin with that needle).



> Last time I saw an IO pressure infused, it was along with Ativan and Morphine since it was very uncomfortable.



Yeah but then again an IV being pressure bagged in isn't too much fun either (speaking from experience).


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## MrBrown (Aug 29, 2011)

If your patient is that crook he needs an IO then get drilling (or screwing, if you still use the Cooks IO needle, or shooting if you use the bone injection gun)

Oh my what dirty business this stuff is 

No need to wait until he is at the hospital for a central line


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## usafmedic45 (Aug 30, 2011)

> No need to wait until he is at the hospital for a central line



Hell, until IO came into fashion for adults, subclavians were not uncommonly part of protocols.  In some places they still are.


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## PFD2171 (Aug 30, 2011)

*Io*

Although pain is a concern a better judgment is the presentation of the patient and the necessity of the fluid, medication. I am sure most would be quick to place the IO once the patient arrested but it better to place it and avoid the arrest if possible.


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