# Humeral head vs tibial IO



## NomadicMedic (Apr 3, 2014)

Anyone seen a study that shows Humeral head IO placement is superior to tibial placement? 

My agency today stated a new policy is that the humeral head is to be the primary site for IO placement. 

I looked quickly, but didn't see anything that jumped out at me.


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## Summit (Apr 3, 2014)

We are now doing humeral head as the primary site unless you cannot get to it.


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## NomadicMedic (Apr 3, 2014)

I just find a tibial IO to be so easy on codes. One medic manages the airway, the second drills an IO, pushes drugs and "runs the code". Everyone is out of each others way and it works.


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## Handsome Robb (Apr 3, 2014)

DEmedic said:


> I just find a tibial IO to be so easy on codes. One medic manages the airway, the second drills an IO, pushes drugs and "runs the code". Everyone is out of each others way and it works.




Agreed. However in systems. Where there's a sole ALS provider on scene or only one able to give meds and control the airway I could see it being useful having everything at the head kinda like with EJs back in the day. 

Hell if I'm at the head and they've got a good EJ and we don't have access yet I'll stick it still.


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## mycrofft (Apr 3, 2014)

JEMS article of a study, 2008:

http://www.jems.com/article/intraosseus/using-humerus-bone-io-access

AND I QUOTE:
"  …The most frequent reason cited for choosing the tibia over the humerus was “too much activity at the torso” (See Table 3 August issue JEMS, p. 56). Other reasons reported were easier identification of the tibia anatomical landmarks, too much fat overlaying the humerus and inability to expose the humerus access site. No complications, such as osteomyelitis, extravasation, displacement or device failure, were reported for either group...
….Conclusions : This observational study demonstrated that the proximal humerus bone is a viable anatomical site for IO vascular access. For those patients with successful IO access at the humerus site, the needle was correctly placed within 30 seconds. EMS providers found both sites to be useful for IO access, although they tended to prefer the tibia over the humerus.   The humerus provides an acceptable alternative insertion site, which may be preferable under certain clinical scenarios, such as lower body trauma or amputation. JEMS"


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## DesertMedic66 (Apr 3, 2014)

We just got humoral head in our protocols as an option. We watched a couple of videos that said it takes less than 3 seconds for medications to reach the heart.


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## STXmedic (Apr 3, 2014)

I'll look for studies when I get home, but I'm very familiar with the guys who developed it. Per them, the humoral does get significantly better flow. 

Unfortunately, the proximal humorous isn't incredibly stable, and it puts the line right in the middle of everything else going on. Because of this, many down here have began moving to the distal femur.

Highest flow of any location? Iliac crest


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## chaz90 (Apr 3, 2014)

STXmedic said:


> I'll look for studies when I get home, but I'm very familiar with the guys who developed it. Per them, the humoral does get significantly better flow.
> 
> Unfortunately, the proximal humorous isn't incredibly stable, and it puts the line right in the middle of everything else going on. Because of this, many down here have began moving to the distal femur.
> 
> Highest flow of any location? Iliac crest



The reason given during our policy change roll out to numeral head as primary was also that the flow was better/closer to core. It's interesting to me because I had never heard of it as a preferred site over the proximal tibia prior to today. I thought the video I had seen showed excellent circulation from tibial insertion, but I'll have to find it again and check it out. Interesting points from all of you!

Also, did you mean to type distal femur??


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## DesertMedic66 (Apr 3, 2014)

chaz90 said:


> The reason given during our policy change roll out to numeral head as primary was also that the flow was better/closer to core. It's interesting to me because I had never heard of it as a preferred site over the proximal tibia prior to today. I thought the video I had seen showed excellent circulation from tibial insertion, but I'll have to find it again and check it out. Interesting points from all of you!
> 
> Also, did you mean to type distal femur??



I would assume distal femur


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## STXmedic (Apr 3, 2014)

Yes, distal femur. Better flow than tibia, and close to the core but not in the way like the humorous. The system where the two primary developers are from allow their medics to drill literally any bone as long as they can justify it. 

Common sites I've seen listed in protocol around here:
Proximal tibia*
Distal tibia
Distal femur*
Proximal humorous*
Iliac crest
Sternum

*Most common


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## chaz90 (Apr 3, 2014)

Huh. Learn something new every day. Are they precise about landmarks with some of the more exotic sites, or is it pretty much "use the proper bit to get into the intermedullary space and not infiltrate"?


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## STXmedic (Apr 3, 2014)

I'm sure they prefer the standard sites with accepted landmarks. But according to their clinical guy, "Any bone is fair game."


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## TransportJockey (Apr 3, 2014)

Humeral head insertion, at least with the EZ-IO, is rather straightforward with easy to find land marks. I prefer it now that I've done it a few times... but the needle it uses is huge


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## Tigger (Apr 4, 2014)

STXmedic said:


> I'll look for studies when I get home, but I'm very familiar with the guys who developed it. Per them, the humoral does get significantly better flow.
> 
> Unfortunately, the proximal humorous isn't incredibly stable, and it puts the line right in the middle of everything else going on. Because of this, many down here have began moving to the distal femur.
> 
> Highest flow of any location? Iliac crest



I know those needles are pretty well anchored into the bone, however it seems to me that tibia and femur placements are still safer when it comes avoiding getting hung up extricating someone from a house with tight hallways or the like.


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## STXmedic (Apr 4, 2014)

Agreed.

DE and Chaz- When y'all start using them, a tip for insertion and prevention of dislodgement: Take their hand and rotate it inward, so that the back of their hand is against their thigh. Then secure their hand in that position by either putting it in their wasteband or belt. When you do that, it rotates the humerus into the ideal position for insertion, and prevents the arm from moving and dislodging the needle.


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## jwk (Apr 4, 2014)

STXmedic said:


> Yes, distal femur. Better flow than tibia, and close to the core but not in the way like the humorous. The system where the two primary developers are from allow their medics to drill literally any bone as long as they can justify it.
> 
> Common sites I've seen listed in protocol around here:
> Proximal tibia*
> ...



humorous=funny

humerus=upper arm bone

 sorry, driving me crazy


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## STXmedic (Apr 4, 2014)

jwk said:


> humorous=funny
> 
> humerus=upper arm bone
> 
> sorry, driving me crazy



Haha thanks  Was too lazy to look up which was which, so I was content with the lack of a red underline :lol:


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## NomadicMedic (Apr 4, 2014)

I've only done one, and we use the long "yellow" needle set for adult humeral head placement. (I'm not at work so I don't have one in front of me.) 

Seems to be okay, I just remember Vidacare touting access in the tibia having vascular availability just as fast as any other peripheral IV. I'm curious how much faster (read: better) the humeral head placement is. Or if it is at all.


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## Handsome Robb (Apr 4, 2014)

STXmedic said:


> Haha thanks  Was too lazy to look up which was which, so I was content with the lack of a red underline :lol:



Damn I was gonna say autocorrect hosed you. 

No...you're just an idiot.


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## Carlos Danger (Apr 4, 2014)

DEmedic said:


> I'm curious how much faster (read: better) the humeral head placement is. Or if it is at all.



I can't imagine it being a clinically significant difference. Maybe it takes a drug 7 seconds to reach the central circulation instead of 3. I just go for whichever site is more convenient. 

If it takes you a few more seconds to get a humeral IO, or if it becomes dislodged because it's exposed, then you've easily erased any slight time advantage that the humeral site offers.


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## STXmedic (Apr 4, 2014)

Robb said:


> Damn I was gonna say autocorrect hosed you.
> 
> No...you're just a lazy idiot.



Fixed


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## Christopher (Apr 4, 2014)

DEmedic said:


> Anyone seen a study that shows Humeral head IO placement is superior to tibial placement?
> 
> My agency today stated a new policy is that the humeral head is to be the primary site for IO placement.
> 
> I looked quickly, but didn't see anything that jumped out at me.



We have humeral as an option, but we don't use it in a code situation.

After watching numerous guides and palpating everybody who'll stand still, I still do not find the humeral head to be a reliable landmark. I've even watched a Vidacare employee drill another employee live...still not convinced. As long as I've got a proximal tibia, palpable in everybody who isn't a BKA, I'm going to avoid the humeral head. Too much going on up there.


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## cruiseforever (Apr 4, 2014)

Halothane said:


> I can't imagine it being a clinically significant difference. Maybe it takes a drug 7 seconds to reach the central circulation instead of 3. I just go for whichever site is more convenient.
> 
> If it takes you a few more seconds to get a humeral IO, or if it becomes dislodged because it's exposed, then you've easily erased any slight time advantage that the humeral site offers.



When this was brought up at our service last week our medical director said there would be very little difference.  But he also said he was going to look for more data.  

When using the E-Z IO on adults do you use both the blue and yellow needles?  I have heard services are starting to use just the yellow to help keep the number of needles carried in half.


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## NomadicMedic (Apr 4, 2014)

We carry 4 needle sets in each set of ALS gear; a pedi, two adult and a Bari. 

They specifically mentioned faster vascular availability in our con ed session. I'm curious if I'll be subject to QI scrutiny if I continue to place tibial IOs.


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## Summit (Apr 4, 2014)

EZ IO mantra: If you looking for something humerus, put a yellow in your fellow."

Long needle.

We are placing the arm palm down over the umbilicus, then using tape/coban to pin the arm in that position. This gives good site exposure.


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## Handsome Robb (Apr 4, 2014)

We only care pink and blue. Only can access proximal tibia. 

So stupid. I've had multiple arrests we couldn't get access on and I ended up pulling the King and intubating so I could dump drugs down the tube...so stupid. I wasn't happy either time and I made damn sure our Ops director and Supervisor knew when they popped my back doors open to help me unload. 

Only required to carry 1 pedi but I carry two. Seen too many missed.


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## Ridryder911 (Apr 5, 2014)

If you contact Vidacare they can give you more information on data studied. I am an educator for them and we did studies displaying the increase time and effectiveness of sites. If you look on youtube as well; one can see the immediate time response under fluoroscopy. 

We also performed the variations of I/O vs I/V, ETT, etc.. no comparrision. 

The main reason is also the infusion rate has been more sucessful at the head of the humerus. I performed some I/O on cadevers using the femur, fibula route as well. I know they had been attempting to obtain potential different sites for uses but still pending FDA approval. I have not heard of any change as of yet. 

I will try to upload some pics later of some of the fluroscopy and insertion sites. .. 

R/r 911


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## TransportJockey (Apr 5, 2014)

Ridryder911 said:


> If you contact Vidacare they can give you more information on data studied. I am an educator for them and we did studies displaying the increase time and effectiveness of sites. If you look on youtube as well; one can see the immediate time response under fluoroscopy.
> 
> We also performed the variations of I/O vs I/V, ETT, etc.. no comparrision.
> 
> ...



We just had an inservice here at my hospital about that. The tapes looked like one hell of an improvement and we've noticed a much faster infusion rate in the trauma room, especially with our level one


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## Carlos Danger (Apr 5, 2014)

TransportJockey said:


> We just had an inservice here at my hospital about that. The tapes looked like one hell of an improvement and we've noticed a much faster infusion rate in the trauma room, especially with our level one



You actually run a level 1 through an IO?


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## medicsb (Apr 6, 2014)

I'm still skeptical about all the IO hype, especially in cardiac arrest.  Not trying to say it has no use or should not be used, but I do think it is far over used.  I facepalm a little bit whenever I hear of "IO first" protocols for cardiac arrest.  It hasn't been shown to increase rate of ROSC or survival to DC compared to IV, despite being so much quicker.  My inner cynic thinks two things: the IO is an expensive means for paramedics to gain vascular access to perform unproven procedures faster (e.g. RSI or med admin in cardiac arrest); and, it is an attempt to compensate for skill degradation (e.g. too many medics = too little practice with starting IVs on critical patients = poor success).


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## TransportJockey (Apr 6, 2014)

Halothane said:


> You actually run a level 1 through an IO?



They have in the past while waiting for a cordis or other cvc. I've seen it twice now.


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## Carlos Danger (Apr 6, 2014)

medicsb said:


> I'm still skeptical about all the IO hype, especially in cardiac arrest.  Not trying to say it has no use or should not be used, but I do think it is far over used.  I facepalm a little bit whenever I hear of "IO first" protocols for cardiac arrest.  It hasn't been shown to increase rate of ROSC or survival to DC compared to IV, despite being so much quicker.  My inner cynic thinks two things: the IO is an expensive means for paramedics to gain vascular access to perform unproven procedures faster (e.g. RSI or med admin in cardiac arrest); and, it is an attempt to compensate for skill degradation (e.g. too many medics = too little practice with starting IVs on critical patients = poor success).



I kind of agree. Just like prehospital RSI, VL, TXA, ketamine, EKG's, capnography, etc, the IO is a great tool but has not revolutionized prehospital care as some had hoped. Rarely do "new" things such as these live up to the hype. 

On the other hand, it is a great tool. We've all seen patients who were very time consuming if not impossible to get a PIV started on. Sometimes those patients really do need vascular access for one reason or another, and a good IO device obviates most of those situations.

I was fortunate enough to be the clinical educator at a HEMS program that was part of the pre-market trials of the EZ-IO, so I had a front-row seat to the development of the early recommendations for use. In fact I personally wrote the original sample EMS protocol for use (it was just our agencies IO protocol, that I wrote and was approved by our MD) that appeared on Vidacare's website for some time after the device originally went on the market (in 2004, I think?). At that time they were not marketing it as a "first line" for anything, but simply as an alternative to IV access in patients who were difficult to gain such in. In fact IIRC, the protocol said it was indicated for use in patients "Whose clinical condition _necessitates_ IV access, which was not obtained after 2-3 attempts at PIV placement, or in whom suitable PIV sites cannot be located (i.e., amputated, mangled, or severely burned extremities)". Or something closely along those lines. 

Somehow that reasonable recommendation morphed into the current push to place them right away on arrests. I wish we didn't place quite so much emphasis on resuscitating dead people, and didn't use how good we are at that as a primary measure of the effectiveness of our systems. But that's another topic altogether.


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## Ridryder911 (Apr 6, 2014)

Halothane said:


> Somehow that reasonable recommendation morphed into the current push to place them right away on arrests. *I wish we didn't place quite so much emphasis on resuscitating dead people,* and didn't use how good we are at that as a primary measure of the effectiveness of our systems. But that's another topic altogether.



I believe the most part is that you can't resucitate without an IV .... with that saying, more emphasis should be placed on all levels (cough... especially physicians) on what is best for the patient and family and not what is best to improve skills and practice. Not every code should have attempts of resucitation and or when it is time to quit. 

R/r


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## 9D4 (Apr 11, 2014)

A medic instructor referred to me that the humeral head can tolerate a faster flow rate than the tibia. Not sure if there is any truth to it and I can't find anything.
Edit: Found something and it was false. Article about the benefits of pressure bags, but it mentions flow rates for both. 


> Tibial flow rates were 204.6 ml/min with a pressure bag as compared to 68.2 ml/min without a pressure bag, difference −129.5 ml/min [95% confidence interval (CI): −218.2 to −40.3). Humeral flow rates were significantly faster using a pressure bag (148.1 ml/min) as compared to without (81.8 ml/min), difference −69.6 ml/min (95% CI: −113.9 to −25.3). But the difference of changes ( with or without pressure bag) of flow rate between the tibia and humerus did not show any significance (P = 0.157, Mann-Whitney test).


So, basically. Disregard this post. Hahaha.


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## medicdan (Apr 12, 2014)

9D4 said:


> A medic instructor referred to me that the humeral head can tolerate a faster flow rate than the tibia. Not sure if there is any truth to it and I can't find anything.
> Edit: Found something and it was false. Article about the benefits of pressure bags, but it mentions flow rates for both.
> 
> So, basically. Disregard this post. Hahaha.



Thanks for sharing. Do you have a reference for that?


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## Household6 (Apr 12, 2014)

medicdan said:


> Thanks for sharing. Do you have a reference for that?



Because our EMS director says so is the answer I got when I asked. 

We don't carry a humeral needle.. Is there such a thing? We carry pedi, adult, and bariatric. 2 of each. We won't get shunned if we use the humerus, we're not forbidden to use that site on adults, but it's not an alternative place on peds.

I've never done a pedi, but the FTO says that on infants and toddlers you don't even need to engage the trigger. He says the bones are still soft enough that you can just push them in without drilling or very minimal drilling.


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## 9D4 (Apr 12, 2014)

medicdan said:


> Thanks for sharing. Do you have a reference for that?



www.ncbi.nlm.nih.gov/m/pubmed/19041528/
May be a mobile link. Interesting that it's actually slower in humeral vs tibial. I was taught it was opposite, but guess not.


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## chaz90 (Apr 12, 2014)

Household6 said:


> We don't carry a humeral needle.. Is there such a thing? We carry pedi, adult, and bariatric. 2 of each. We won't get shunned if we use the humerus, we're not forbidden to use that site on adults, but it's not an alternative place on peds.



See, this is why we should get away from referring to the various size IO needles using the terms "pedi, adult, and bariatric." There's no such thing as a dedicated humeral needle, but the largest yellow size (45 mm?) is recommended for almost all adult patients for proximal humeral access. 

Really, we need to recognize that there are plenty of patients with "extra stuffing" on whom proximal tibial IO access can be achieved using the blue (25 mm) driver and plenty of technically pediatric patients who are entirely too large for the small pink needle. Everything should be determined by amount of tissue over the access site and estimated thickness of the bone itself.






9D4 said:


> www.ncbi.nlm.nih.gov/m/pubmed/19041528/
> May be a mobile link. Interesting that it's actually slower in humeral vs tibial. I was taught it was opposite, but guess not.



A quick glance at the article doesn't seem to show the flow rates were significantly different in either access site. The raw number is slightly smaller in humeral access, but with the small sample size and margin of error it's not a statistically significant difference.


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## Ridryder911 (Apr 14, 2014)

9D4 said:


> www.ncbi.nlm.nih.gov/m/pubmed/19041528/
> May be a mobile link. Interesting that it's actually slower in humeral vs tibial. I was taught it was opposite, but guess not.



Actually the article does not point that out, rather tibia and humeral head with a pressure bag vs those without... those with pressure bag infuse faster.. DUH?.. and we call this research? 


R/r 911


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## 9D4 (Apr 14, 2014)

9D4 said:


> A medic instructor referred to me that the humeral head can tolerate a faster flow rate than the tibia. Not sure if there is any truth to it and I can't find anything.
> Edit: Found something and it was false. Article about the benefits of pressure bags, but it mentions flow rates for both.
> 
> So, basically. Disregard this post. Hahaha.





Ridryder911 said:


> Actually the article does not point that out, rather tibia and humeral head with a pressure bag vs those without... those with pressure bag infuse faster.. DUH?.. and we call this research?
> 
> 
> R/r 911


I noted that, sir. It does briefly mention the difference between tibial and humeral. It is an extremely slight difference, but I was told that the humerus takes a massive amount of fluid at a faster flow rate. Which was why I mentioned it, to correct what I had posted earlier.


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## Cbyoung71 (Apr 16, 2014)

Lots of good information here !


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## Harleyjon (Jun 7, 2017)

I am a new medic with only a couple years behind me. I have only done maybe 4 I/O insertions, all proximal tibia. I have stuck with that because a medic of 14 years had talked of the difficulty in site location. The last arrest I was part of I witnessed a (successful)  humeral head insertion and I also have watched a number of videos (Youtube can be a wonderful thing!) It really doesn't appear to be as difficult as I had thought. In school it was taked about But I don't remember any hands on, we only performed the proximal tibial insertion. I will be considering it on the next case.According to the paper presented the flow rates are similar but it does seem that having the med administration site near the head would be convenient since I often am riding with an EMT who cant administer drugs.
Where I am at in Southeast Georgia it seems that I/O access is reserved for cardiac arrest and unresponsive patients with inability to gain IV access. Has anyone out there done an I/O on a conscious Pt? I've seen it done on youtube. What situations would cause you to go to that point? I work on a county 911 ambulance with T/P time ranging from 15 to 30mins.


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## NomadicMedic (Jun 7, 2017)

Harleyjon said:


> I am a new medic with only a couple years behind me. I have only done maybe 4 I/O insertions, all proximal tibia. I have stuck with that because a medic of 14 years had talked of the difficulty in site location. The last arrest I was part of I witnessed a (successful)  humeral head insertion and I also have watched a number of videos (Youtube can be a wonderful thing!) It really doesn't appear to be as difficult as I had thought. In school it was taked about But I don't remember any hands on, we only performed the proximal tibial insertion. I will be considering it on the next case.According to the paper presented the flow rates are similar but it does seem that having the med administration site near the head would be convenient since I often am riding with an EMT who cant administer drugs.
> Where I am at in Southeast Georgia it seems that I/O access is reserved for cardiac arrest and unresponsive patients with inability to gain IV access. Has anyone out there done an I/O on a conscious Pt? I've seen it done on youtube. What situations would cause you to go to that point? I work on a county 911 ambulance with T/P time ranging from 15 to 30mins.




Yeah. I placed a tibial IO on a seizure patient last week. She was postictal, but the flush woke her up fully. She had been in status for 15 minutes and I needed access.


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## Tigger (Jun 7, 2017)

I've drilled two conscious patient's after failing to get access by other means. One was for HyperK (he became less obtunded after getting a gram of calcium and an amp of bicarb bolused...), the other was some sort of odd overdoes where her pressure fell out and we had no other option.


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## DesertMedic66 (Jun 7, 2017)

I have done 2 conscious IOs. One was a diabetic patient who was responsive to verbal stimuli. No where near enough with it for oral glucose, I tried 4 sticks followed by my medic preceptor who tried 4-5. Ended up going distal tibia and it worked fine. 

Second was a self inflicted GSW to the head. Patient AOx4. No IV access at all. I went humeral head with it. Patient had some pain until the lido kicked in. Then fluids went in very quickly with no pressure bag being needed.


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## RocketMedic (Jun 7, 2017)

DesertMedic66 said:


> I have done 2 conscious IOs. One was a diabetic patient who was responsive to verbal stimuli. No where near enough with it for oral glucose, I tried 4 sticks followed by my medic preceptor who tried 4-5. Ended up going distal tibia and it worked fine.
> 
> Second was a self inflicted GSW to the head. Patient AOx4. No IV access at all. I went humeral head with it. Patient had some pain until the lido kicked in. Then fluids went in very quickly with no pressure bag being needed.



Y'all can IO in CA? EZ IO or manual?


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## DesertMedic66 (Jun 7, 2017)

RocketMedic said:


> Y'all can IO in CA? EZ IO or manual?


Yeah we can IO in CA. It depends on your county and company if you have EZ IO or manual. For my county we have the EZ IO with distal tib, proximal tib, and humoral head standing orders.


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## Harleyjon (Jun 7, 2017)

Thanks for the responses guys. It is always nice to have alternate options for different scenarios. Especially for situations which one has yet to encounter.


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## CWATT (Jun 7, 2017)

@Harleyjon - the only consideration re: proximal humoral IO access is for conscious patients who are not able to follow commands.  If they were to lift their arm, the acromium process can make contact with and subsequently dislodge the needle.  For these patients, a proximal tibial placement may be a more suitable site.


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## Harleyjon (Jun 7, 2017)

Very good point @CWATT  I will keep it in mind. Thanks!


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## SandpitMedic (Jun 20, 2017)

TransportJockey said:


> Humeral head insertion, at least with the EZ-IO, is rather straightforward with easy to find land marks. I prefer it now that I've done it a few times... but the needle it uses is huge


I second that. 
And it flows like a champ.


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## Cowboy (Jul 11, 2017)

Yeah we have been talking about using the femur for awhile now now. We do use it in pediatrics right now.


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## VFlutter (Jul 12, 2017)

CWATT said:


> @Harleyjon - the only consideration re: proximal humoral IO access is for conscious patients who are not able to follow commands.  If they were to lift their arm, the acromium process can make contact with and subsequently dislodge the needle.  For these patients, a proximal tibial placement may be a more suitable site.



Valid concern however I still prefer to go humoral and just secure the arm. Wrist restraint or Coban and keep the arm tucked across the body. Unless they are agitated and flailing about it shouldn't be too much of an issue.


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