# Multiple IV Attempts



## mikie (Apr 14, 2008)

*I tried a search, couldn't find anything specific*

What is your protocol on failed IV attempts?  How many tries do you get?

I BELIEVE (I'm only a Basic, but familiar with the Intermediate/Paramedic  protocols) that they are allowed 2 sticks before having to call MedControl.

For example, for hypoglycemia, dextrose would be administered IV unless after two attempts it has failed, then we use Glucagon (which basics can administer, IM (I'm on an ILS truck, so that's why Glucagon would be administered after attempted Dextrose).  Depending on the Tx time, we would probably be allowed another stick, but ours is usually 5-10min, so we usually don't.  

This is just a scenario for blood sugar, what about other situations?

If protocol only allowed 2 and you couldn't get a hold of MedControl, or whomever, would you try again?

Thanks!

(Lets not turn this into why the 'bad protocol' or why can Basics give IM or IV, etc.....lets just hear about other people's protocol & experience)


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## firecoins (Apr 14, 2008)

emt-b's give glucagon IM?  Thats weird.  

There is no protocol reguarding failed attempts but they are to be kept to a minimum.  Don't ruin access for the ER staff. They will get it if you can't.


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## oneluv79 (Apr 14, 2008)

*Seen something like that....*



mikie333 said:


> *I tried a search, couldn't find anything specific*
> 
> _What is your protocol on failed IV attempts?  How many tries do you get?_
> 
> ...





We arrived on scene (about 9:20 a.m.) after the neighbors thought something was wrong and gained entry into pt/her house, pt was unconscious, not responsive to anything, very rapid respirations/shallow, and was sweating so bad the sofa had a wet body outline...(Pt was diabetic informed by friend) Anyways the IV part, _there were 4+ attempts made (FF/Medic was on L. hand and arm, Paramedic tried R. hand, arm and top of R. foot)_ but nothing (I was on + pressure vents) M.D. advised admin. of drugs (which was carried out by another FF/Medic on scene)... still nothing... transport time to ER was less than one minute... Basically after all of them failed we jetted... Hope this helps....

oneluv79


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## medic_chick87 (Apr 14, 2008)

We're allowed 2-3 IV attempts. If the pt is critical we're allowed to do IO.


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## Ops Paramedic (Apr 14, 2008)

For us there are no restrictions on the number of attempts published in the protocol.  The teaching however is in line with ACLS/PALS etc, whereby it is recommended that after two unsuccesful attempts, you attempt IO.

Great if you have the correct equipment readily availble, otherwise IO is mainly reserved for those who really need them.  Should you take ITLS into consideration, they advocate that scene time is not prolonged for IV access, unless it is needed for serious fluid callenge.

So to answer your question, i would say that this is a practitioner based choice, and depending on what the purpose of the IV is.  

PS-Last night we sited a Femoral IV, prior to Peripheral or External Jugulars.  The reason/motivation was that we could not get to the patient's arms or neck.


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## triemal04 (Apr 14, 2008)

mikie333-  would it be possible (pleasepleaseplease) for you to take a look at your protocolls ASAP and post the actual restrictions/guidelines for venous access?  I'm only asking because it's rather...um...insane...to make someone call medical control if they are unable to start an IV, especially if it's after only 2 starts.  I'm just curious, but were you specifically talking about with hypoglycemic pt's (still wrong) or was it an overall restriction?

I'll hold further comments till this get's cleared up.


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## ffemt8978 (Apr 14, 2008)

Our protocols are two attempts for stable patients.  If they're critical, it's two attempts and then go for the IO.


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## MSDeltaFlt (Apr 15, 2008)

Go for the neck.


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## mikie (Apr 15, 2008)

triemal04 said:


> mikie333-  would it be possible (pleasepleaseplease) for you to take a look at your protocolls ASAP and post the actual restrictions/guidelines for venous access?  I'm only asking because it's rather...um...insane...to make someone call medical control if they are unable to start an IV, especially if it's after only 2 starts.  I'm just curious, but were you specifically talking about with hypoglycemic pt's (still wrong) or was it an overall restriction?



I was just throwing in the hypoglycemia pt as a scenerio regarding IVs and another medicinal option (Glucagon), since it can be administered if they can't 'protect their gag reflex'

This is from my big protocol book they issued us (it has all providers in it)



> #14- If blood returns through the catheter, proceed with insertion.  If you do not see blood return, release the tourniquet and discontinue the attempt.  It time and patient condition allows, you may attempt another site with a new catheter (do not exceed more than two (2) attempts



That was step #14 in the Intravenous Cannulation Procedure

-hope that helped


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## mikie (Apr 15, 2008)

MSDeltaFlt said:


> Go for the neck.



Could you give some examples when you would go for the EJ (right?)? As opposed to either trying the arm/hand?

Thanks


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## paramedix (Apr 15, 2008)

Zero time IV... If I can and its possible I don't site IV on scene. Do it en-route to hospital. 

There is no guidance according how many attempts you have for an IV. As mentioned earlier, ITLS protocols. Don't waste time though, get help if you cannot, but don't delay transport if the patient can be safely moved.


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## TKO (Apr 15, 2008)

Up north here, I can perform 3 pokes and my IV qualified partner can perform another 3 PRN.

With diabetics (especially IDDMs) we generally try to avoid the hand since they are highly prone to infection and have microvascular issues (it's all about Quality of Life and how much they'll love you if they lose their hand) and we are putting Dextrose in those tiny papery veins that are oh-so susceptible to extravasation.

And like I mentioned before, we'll roll the UnCx pt into the recovery position and apply a small amount of GlucoGel into the dependent buccal pouch of the mouth to absorb or drool out.

And if or when that fails, I have glucagon SC.


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## DocPetey (Apr 15, 2008)

3 pokes stable.  2 pokes critical and then IO.  EJ if you're gooooooooooooood.

ewwwwwwww........IO.   (personal pucker factor for Your's Truly.)

Dual EJ's?  That's some Cool Points with the ED staff around here.  First time I did that (When I was in the Navy), I went home  after shift so juiced up I pounced on the husband with evil intent.


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## MSDeltaFlt (Apr 15, 2008)

If arm veins are crappy, and they NEED an IV (hypotension, hypoglycemia, seizure, brady), I might give an arm 1 shot, MAYBE 2, then go for EJ.  It's a peripheral vein that's not used very often so you can usually get it.


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## Hastings (Apr 15, 2008)

Two IV attempts per person, unless only one medic is available. Typically three IV attempts total before giving up. IO after one-two attempts if vascular access is necessary.

And in comparison...

One intubation attempt per person, unless only one medic available. Two attempts total before Combitube.


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## eggshen (Apr 18, 2008)

No statement regarding # of attempts. I think it is implied that one will not treat the pt. as a pin cusion. As far as IO, it's indicated for arrest or peri-arrest only. Though some agencies 'round here have been know to push D-50 through an IO and release. Shame

Egg


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## Short Bus (Apr 19, 2008)

eggshen said:


> No statement regarding # of attempts. I think it is implied that one will not treat the pt. as a pin cusion. As far as IO, it's indicated for arrest or peri-arrest only. Though some agencies 'round here have been know to push D-50 through an IO and release. Shame
> 
> Egg



WOW :sad:

We do not have a limit.  If you need it, try for it.  We can go to an IO after trying one IV.  Just remember, arms, legs, feet, neck, everything is fair game.  Don't think that you have to have it in the arm.


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## triemal04 (Apr 19, 2008)

Interesting to see the variance in protocols...and more proof that for some reason many doctors are not comfortably in letting their paramedics use their own judgement in treating their patients.

Starting an IV is not (or at least should not be) something that needs to be spelled out in explicit detail in the protocols; if needed you do it.  If you are unable to and steel need access, you move on to your secondary device if you have one.  And all paramedics should be well educated to know when it is pointless and/or uneccasary to continue to stick someone; this is something that every service should be ensuring with good QA/QI and in house training.  Not to mention something that should be covered in learning to be a paramedic.  

I mean come on, if we aren't trusted enough to use our own judgement in starting an IV, is it any wonder that people have such problems with RSI, intubation, cardioversion, minimal on-line control, med administration, spinal clearance and the list goes on.  Does anybody still have doubts about EMS education in the US?  

(there is no specific limit here; if the pt needs venous access they get it.  Like eggshen, we are expected to base the number of times we stick someone on what is wrong with them and why we are trying for a line with the understanding that poking them when it's pointless is wrong.  As for going to an IO...that can be the first access point if the paramedic deems it neccasary.)


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## MedicDoug (Apr 20, 2008)

No specifics in protocol here either, although under IO it says PED after one IV attempt and IV access is essential, Adult Cardiac Arrest after 3 attempts. 3 seems to be the accepted standard per provider (on the rare occasion there's more than one medic on scene). Our local diagnostics lab has a 3 sticks per practitioner policy.


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## ERnurse17 (May 14, 2008)

we have three chances to get a line.  after that we all med control.  usually after the first failed attempt with a diabetic pt we adminster glucogon incase we miss the next one.


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## TEK 679 (May 28, 2008)

We can try three times then you go IO if unstable under Dr. order.


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## mikeylikesit (May 28, 2008)

ffemt8978 said:


> Our protocols are two attempts for stable patients.  If they're critical, it's two attempts and then go for the IO.



Same here 2 then intraosseous.


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## LIFESAVER4U (Jun 3, 2008)

We are allowed 2 attempts then if there isnt another ALS peron there we call med control to see other options. If its a code we can do meds down the et. If its diabetic we give glucogan IM if we can't do D50.


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## philfry (Jun 5, 2008)

Here our ALS procotol is 2 attempts at IV access.  Two failed attempts allows for IO placement and Glucogen IM.  Our EJ protocol simply states that it may be attempted if no peripheral sites are available.  Gives us some room to do what we feel is necessary.


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## rhan101277 (Jul 10, 2008)

I didn't know what IO was, until mikey typed in intraosseous.  I knew what IV meant and IM.  So you actually give it in the bone marrow?  Isn't that painful, also bones bleed as well.


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## KEVD18 (Jul 10, 2008)

yes it delivered into the bone. yes, it can be painful, which is why most places have added lido to the io protocols. 

who starts an io line and then releases a pt?

who still gives drugs down a tube?


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## upstateemt (Jul 17, 2008)

As an EMT and  a Hospital RN my "personal" protocol has always been two sticks.  After that I defer to someone else.  In hospital there is always someone to give it a try, out of hospital I don't want to blow every available vein and leave the ER with nothing.


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## reaper (Jul 17, 2008)

Studies have showed that an IO hurts as much as an IV. It is the infusion of fluids that is painful. That is why the Lido is given prior to fluids.


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## Ridryder911 (Jul 17, 2008)

reaper said:


> Studies have showed that an IO hurts as much as an IV. It is the infusion of fluids that is painful. That is why the Lido is given prior to fluids.



Actually it is only compared a 3/10 on a pain scale.. not too bad in all accounts. Lidocaine is not given for the insertion rather 5mg of 1% is mixed into a liter of Saline for the infusion. The pain increases because one usually has to use pressure devices to "force" the fluid and thus causing inside pressure on the periosteum. This trick works great for conscious patients...

R/r 911


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## mikie (Jul 18, 2008)

I really don't know much about IO...could some one either provide a link or explain the basics...

I got the part where it goes into the bone, but...where? how? is the dosing of medication different?  can some meds not be used?

Thanks!


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## mikeylikesit (Jul 18, 2008)

mikie333 said:


> I really don't know much about IO...could some one either provide a link or explain the basics...
> 
> I got the part where it goes into the bone, but...where? how? is the dosing of medication different? can some meds not be used?
> 
> Thanks!


This should cover ya!

http://www.emedicine.com/PED/topic3053.htm

it has pics and everything you need.


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## Hastings (Jul 18, 2008)

Also, an IO is treated the same way as an IV. Mostly because while it penetrates the bone, it's still simply entering the blood supply. Doses are the same, etc, etc. The flash while doing it is different, and pressure is usually required to give fluids.


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## MedicPrincess (Jul 18, 2008)

Two attempts.  If Diabetic, go to Glucagon IM.  

Additional IV attempts can be made, or we have IO.  We can also go straight to IO in some situations, and establish IV as our second line.

I did recently learn the Chief of Trauma Services at one of our Trauma Centers HATES IO's.  We took a TA pt in there, and in the middle of my report she looked at me and said, "Get that IO out of him!"  Talked to one of the nurses later and she told me its just something the Dr doesn't like.  No reason needed.


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## Ridryder911 (Jul 19, 2008)

mikie333 said:


> I really don't know much about IO...could some one either provide a link or explain the basics...
> 
> I got the part where it goes into the bone, but...where? how? is the dosing of medication different?  can some meds not be used?
> 
> Thanks!



Everything you wanted to know & more!...

http://www.vidacare.com/

R/r 911


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## reaper (Jul 19, 2008)

Rid,

 When Vidacare came and did the training on the EZ-IO, They suggested using the prefilled lido and pushing the whole dose in the IO, before running fluids. I kinda like the diluting it in the liter of NS.


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## Ridryder911 (Jul 19, 2008)

reaper said:


> Rid,
> 
> When Vidacare came and did the training on the EZ-IO, They suggested using the prefilled lido and pushing the whole dose in the IO, before running fluids. I kinda like the diluting it in the liter of NS.



One of the teaching hospitals in my ares did a 3 year study of EZ I/O on conscious patients. Usually football players that were severely dehydrated, etc.. That there recommendation. I would fear bolusing Lidocaine to anyone, it would have the same results as me administering for cardiac, etc.. IN other words, if you had an escape or brady with PVC's it could result in aystole. Where as 25mg diluted, one would have to be extremely cautious but may not be as extreme. 

Now I ask how many services carry pressure infusers?


R/r 911


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## newbie (Jul 19, 2008)

Ridryder911 said:


> Now I ask how many services carry pressure infusers?
> 
> 
> R/r 911



we carry them


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## reaper (Jul 20, 2008)

Rid,

 I asked the Dr. doing the training the same question. He stated that it would not effect cardiac at all! I found that hard to believe.

Yes, we did carry pressure infusers.


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## Ridryder911 (Jul 20, 2008)

reaper said:


> Rid,
> 
> I asked the Dr. doing the training the same question. He stated that it would not effect cardiac at all! I found that hard to believe.
> 
> Yes, we did carry pressure infusers.



I believe what he is referring to is that most of the time Lidocaine has no effect on the cardiac (if there is nothing wrong). Just because it is administered I/O does not change the effect of the medication, the same as administering it per I.V.. .

Personally, I would hold off the Lido if there was a contraindication to do so...

R/r 911


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## mikeylikesit (Jul 20, 2008)

we still carry pressure infusers.


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## shannon williams (Jul 28, 2008)

If we can't get IV access, we attempt IO.


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## mikie (Jul 28, 2008)

So for all those whose protocol says to go to IO...what if you can't get IO either?  (or are they not that hard to miss?)


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## shannon williams (Jul 28, 2008)

any other venous site?  If you can't get venous access, you really can't deliver very many meds.  We usually attempt multiple IV sites, 2 attempts per person, hope to hell someone will get one, but if you can't successfully place an IO, in any of the sites, I think it would be time to be at the back door, or call med.control.


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