Tibial IO Access Efficacy in Cardiac Arrest

M

MedicJoshua

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Recently saw some comments on a JEMS article saying tibial IO vascular access isn't very efficient or effective in cardiac arrest. Does anyone have any articles or data on this subject?

Thanks.
 
EpiEMS

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MedicJoshua said:
tibial IO vascular access isn't very efficient or effective in cardiac arrest
Click to expand...

Plausible:

Table 3
Flow rate available with peripheral intravenous site according to catheter size and with intra-osseous access according to insertion site

Studies Flow rate (mL/min)
Insyte Autogard®* (Becton ****inson, Sandy, UT, USA) 14 Gauge: 330
16 Gauge: 193
18 Gauge: 95
20 Gauge: 61
Hammer et al., 2015 [15]** EZ-IO tibia: 27 ± 5/69 ± 54
EZ-IO humerus: 16 ± 3/60 ± 44
FAST1 sternum: 53 ± 2/112 ± 47
Ong et al., 2009 [36]** EZ-IO tibia: 73 ± 35/165 ± 112
EZ-IO humerus: 84 ± 38/153 ± 65
*Maximum flow rate available (information provided by the manufacturer)

**Flow rate without/with pressure bag inflated at 300 mmHg
Click to expand...

Not necessarily "true," though:

There were significant differences in Cmax between the sternal IO and IV (P = .009) and tibial IO and IV (P = .03) groups but no significant difference between tibial and sternal IO groups (P = .75). Significant differences existed in Tmax between the tibial IO and IV (P = .04) and between tibial IO and sternal IO (P = .02) groups but no difference between the sternal IO and IV groups (P= .56). Intravenous administration of 1 mg of epinephrine resulted in a serum concentration 5.87 and 2.86 times greater than for the tibial and sternal routes, respectively.
Click to expand...

I guess the big question is - are you comparing tibial IO to humeral IO to sternal IO, or tibial IO to IV, or what?
 
C

CWATT

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What I find odd is when I participated in an Ez-IO cadaver lab, I observed near instantaneous inflation of the R. Subclavian on injection of a 10ml NaCl bolus via the proximal humoral site. Since cadavers are the 'final stage' of cardiac arrest, I'm wondering how there could be low serum concentrations ASSUMING the IO site was properly flushed prior to Epi admin. Perhaps the study was done incorrectly where the IO was inserted and not flushed. ???

Side note - Who uses sternal route anyway??

Also, can someone please help me understand the two flow rate factors on Table 3? The +-/+-
 
EpiEMS

EpiEMS

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CWATT said:
Side note - Who uses sternal route anyway??
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Very common in the military (for e.g., see "Placement of Tibial Intraosseous Infusion Devices")

CWATT said:
Also, can someone please help me understand the two flow rate factors on Table 3? The +-/+-
Click to expand...

The figures are the mean flow rates +/- the standard deviation. These:

Table 3
Flow rate available with peripheral intravenous site according to catheter size and with intra-osseous access according to insertion site

Studies Flow rate (mL/min)
Insyte Autogard®* (Becton ****inson, Sandy, UT, USA) 14 Gauge: 330
16 Gauge: 193
18 Gauge: 95
20 Gauge: 61
Hammer et al., 2015 [15]** EZ-IO tibia: 27 ± 5/69 ± 54
EZ-IO humerus: 16 ± 3/60 ± 44
FAST1 sternum: 53 ± 2/112 ± 47
Ong et al., 2009 [36]** EZ-IO tibia: 73 ± 35/165 ± 112
EZ-IO humerus: 84 ± 38/153 ± 65
*Maximum flow rate available (information provided by the manufacturer)

**Flow rate without/with pressure bag inflated at 300 mmHg
Click to expand...

The last four are subject to some conditions, as indicated by the asterisks.

Also, flow rate and serum concentration, I would suppose, are not necessarily going to be related. You can flow lots of a drug in, but peak serum concentration timing is influenced by other factors, I believe. So, in addition to the differences that I mentioned earlier, "efficiency" is a broad question:

That is to say, are we talking about:
1) Efficiency by route (sternal IO vs. tibial IO vs. humeral IO vs. IV vs. PICC, etc.)
2) Efficiency by time to peak serum concentration of the drug?
3) Something else?
 
MackTheKnife

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CWATT said:
What I find odd is when I participated in an Ez-IO cadaver lab, I observed near instantaneous inflation of the R. Subclavian on injection of a 10ml NaCl bolus via the proximal humoral site. Since cadavers are the 'final stage' of cardiac arrest, I'm wondering how there could be low serum concentrations ASSUMING the IO site was properly flushed prior to Epi admin. Perhaps the study was done incorrectly where the IO was inserted and not flushed. ???

Side note - Who uses sternal route anyway??

Also, can someone please help me understand the two flow rate factors on Table 3? The +-/+-
Click to expand...
Sternal? Military uses it with the FAST device.

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SpecialK

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I'm not sure why'd you bother gaining IO access in a cardiac arrest given there is no good evidence IV drugs in cardiac arrest do anything (unless of course, there's a scenario where the patient can have the cause of their cardiac arrest reversed with immediate access to a medicine or IV fluid and IV access is not obtainable) and an EZIO needle costs something like $100 or more each, whereas an IV catheter costs about a dollar?

IIRC when I was looking at London they said you had to have a minimum of three attempts at IV access in a cardiac arrest including an EJ before going to IO. I tend to agree.
 
EpiEMS

EpiEMS

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SpecialK said:
I'm not sure why'd you bother gaining IO access in a cardiac arrest given there is no good evidence IV drugs in cardiac arrest do anything
Click to expand...

Also, this. But yeah, protocol would be the why, unfortunately.

I have to imagine that there is some volume discount, but the figure I see is like $150+ for sets of 5 EZIO needles.
 
E tank

E tank

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A one hundred dollar item in the context of what can amount to a 5 figure resuscitation and possibly a 6 figure discharge to home seems like a bargain if it's all you have and actually helps.
 
Gurby

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SpecialK said:
I'm not sure why'd you bother gaining IO access in a cardiac arrest given there is no good evidence IV drugs in cardiac arrest do anything

IIRC when I was looking at London they said you had to have a minimum of three attempts at IV access in a cardiac arrest including an EJ before going to IO. I tend to agree.
Click to expand...

EpiEMS said:
Also, this. But yeah, protocol would be the why, unfortunately.

I have to imagine that there is some volume discount, but the figure I see is like $150+ for sets of 5 EZIO needles.
Click to expand...

You use an IO because it's fast, easy, simple, allows you to get it done and then go back to focusing on more important things.

3 IV sticks during a cardiac arrest and THEN drilling an IO is such a colossal waste of the paramedic's time and mental energy during a code. You just wasted like 3+ minutes doing something that should have taken 30 seconds. You could have instead spent that time reviewing patient's med list, talking to family and gathering more information, thinking about possible reversible causes, doing literally anything else would be more productive than sitting there trying to fish an IV into a vein with no blood pressure so you can give medications that - as you guys pointed out - probably don't do anything meaningful anyways.

If you're in the ED and have an army of people, then sure have somebody try for IV access. If you're a solo medic working with an EMT and a few firefighters, I think IO is the correct choice and it's not even close. Tell me why I'm wrong.

If you want to argue that we shouldn't even obtain access at all then you can probably make a good argument, but that's above our pay grade to think about. Pretty sure in the US if you roll up to the ED with a code and haven't given any drugs you're gonna lose your license.
 
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EpiEMS

EpiEMS

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@Gurby, I'm in total agreement with your rationale for IO over IV in a code (or other similarly critical situation where spending time getting an IV would be time better spent on other things but some sort of venous access is necessary), for, as you say:

Gurby said:
3 IV sticks during a cardiac arrest and THEN drilling an IO is such a colossal waste of the paramedic's time and mental energy during a code.
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My point of agreement with @SpecialK, and I hope you too would agree, is what you discuss here:

Gurby said:
If you want to argue that we shouldn't even obtain access at all then you can probably make a good argument, but that's above our pay grade to think about. Pretty sure in the US if you roll up to the ED with a code and haven't given any drugs you're gonna lose your license.
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Obviously, that last sentence is super important. I would disagree, though, that it is above our pay grade to think about it -- it is certainly above mine (or my ALS partner's, say) to withhold the usual ACLS drugs...sadly enough.
 
S

StCEMT

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I don't necessarily think an IV is a bad choice, IF you limit it to a quick 5 second check and know you have a good spot you can get. I've done it, I was in the right spot for it and we were still setting up anyway. If starting an IV is going to take unnecessarily long or the first attempt fails, then by all means go IO. Honestly I'd just go for the IO initially anyway unless I had another medic or two there. If we got everything settled in then I would at least start an IV further down the line just simply as a back up access point.
 
G

GMCmedic

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Gurby said:
If you want to argue that we shouldn't even obtain access at all then you can probably make a good argument, but that's above our pay grade to think about. Pretty sure in the US if you roll up to the ED with a code and haven't given any drugs you're gonna lose your license.
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You had me up until these two parts. WE are exactly the people that need to be thinking about these things.

Ive rolled into the ED on at least 3 occasions without having given meds, still working.


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Gurby

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GMCmedic said:
You had me up until these two parts. WE are exactly the people that need to be thinking about these things.

Ive rolled into the ED on at least 3 occasions without having given meds, still working.
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Thinking is great - I probably worded that poorly - but protocols exist for a reason. A committee somewhere of MD's and PhD's who spend their entire lives studying and researching this stuff think that we should do it a certain way. You better have a damn good reason and approval from medical control if you're going to withhold ACLS drugs during a code.
 
S

StCEMT

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To be fair, the AHA generally seems to be slow at adopting good changes to the arrest guidelines.
 
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