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Humeral head vs tibial IO
- Thread starter NomadicMedic
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Christopher
Forum Deputy Chief
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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.
cruiseforever
Forum Asst. Chief
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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.
OP
OP
NomadicMedic
I know a guy who knows a guy.
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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.
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.
Summit
Critical Crazy
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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.
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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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.
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.
Ridryder911
EMS Guru
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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
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
TransportJockey
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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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You actually run a level 1 through an IO?
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).
TransportJockey
Forum Chief
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They have in the past while waiting for a cordis or other cvc. I've seen it twice now.
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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
EMS Guru
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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
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.
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.
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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.
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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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.
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.
Ridryder911
EMS Guru
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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.