Intraosseous access in cardiac arrest.

[Smash]

Another IO thread for y'all, this time with a snazzy poll (I hope; never tried that before)

I'm interested in finding out how people utilize intraosseous (IO) access in cardiac arrest. I'd like to know if it is routine, only used if IV access is difficult or prolonged, or never used at all.

Most importantly, I would like to know your rationale for whichever option it is you chose, so please add a post as well as a vote.

Many thanks,

Smash

 

[MrBrown]

IO access is in the Clinical Procedures for patients who have a life threatening need for medicine or fluid where IV access has been unsuccessful

If Brown can't put a drip into some bloke in cardiac arrest, it is reasonable to attempt IO access.

Brown remembers way back to Mobile Intensive Care Officer training in 1992 where it were proclaimeth that drugs in cardiac arrest have little effect

Gosh Brown is so torn

 

[Shishkabob]

I drop an IO first thing on a cardiac arrest, not even attempting to look for an IV.


I do an IO first because it's faster, easier, and I can get it done in seconds and move on to the next thing I have to do. Being the only ALS provider on the vast majority of the arrests, I don't have time to waste attempting IVs when I can just drill in to the tibia and be done with it and move on to the plethora of other things I need to get done.



Infact, in all the arrests I've done, I've only ever done a single IV, and that's because the patient was too obese and the IO wasn't long enough. I was actually kind of shocked that I was able to get an IV on that one, let alone first try...

 

[MrBrown]

I do an IO first because it's faster, easier, and I can get it done in seconds and move on to the next thing I have to do. Being the only ALS provider on the vast majority of the arrests, I don't have time to waste attempting IVs when I can just drill in to the tibia and be done with it and move on to the plethora of other things I need to get done.

What plethora of other things do you have to do?

Circulatory access for drugs and fluid is at the bottom of our cardiac arrest procedure, above only intubation.

 

[Shishkabob]

You mean like every single other thing that has to be done in arrest before you're able to actually call it? I'm going to assume you've done atleast one cardiac arrest, therefor I won't get in to a list of what is done on them.




No reason to spend attempt after attempt trying to get an IV, or looking for a suitable site, when you can just pop an IO in and be done with it, regardless of supposed of efficacy (or lack) of medications.

 

[MrBrown]

You mean like every single other thing that has to be done in arrest before you're able to actually call it?

Brown finds it interesting that you mention needing to do lots of things as a reason to use an IO as there are really not a lot of things you have to do at a cardiac arrest.

- CPR
- Defibrillation as appropriate
- Ventilation
- Adrenaline

... in that order

Even if there are only two of you all that you need to do is have somebody do CPR while you put on the defibrillation pads. Ventilation is not a priority and can be left until the first two minutes of CPR (and first shock if necessary) has been delivered, although there is time to shove in an oral or laryngeal mask airway between getting the defibrillation pads on and the first two minutes of CPR being delivered.

If the local redneck yahoo volunteer firefighters have shown up as well more the merrier, get them to do CPR while one Ambulance Officer secures an airway and if you are that set on getting a drip, that frees you up to do that.

 

[Shishkabob]

I initially had a list but took it out because I thought you've actually done a code, soooo...apparently codes are run differently down south...


(Not in order)
Establish an airway
Establish a line
Monitor the monitor
Shock if needed
Give medications
Gather a history
Get a BGL and check other reversible causes
Confirm patency of airway, and if necessary move on to the next step, like intubation
Make sure ventilations are correct and adequate
Make sure compressions are correct and adequate
Talk to the family
etc etc etc

And that doesn't even include getting ROSC. It's by no means "hard", especially once you've done a couple, but it is still quite a bit that needs to be done, especially in the opening part, before you even think about calling it.



Again, it takes seconds to do an IO... even if your disagree with the evidence on medications in a cardiac arrest, there's no reason to not get a line, or even get one early on. The evidence still backs up giving medications to reversible arrests, and you can't give the medications without having a line.

 

[MrBrown]

Mate, it seems like you are making this way more complex than you need to.

Establish an airway

Can be done in five seconds; if you do not carry the LMA then shove an oral airway in. One of your redneck volunteer firefighter/EMTs can do this

Establish a line

At some point, most cardiac arrests in Brown's experience this is not done until the second cycle of CPR or later as adrenaline is not given until at least the end of the second cycle.

Monitor the monitor

This is a semi valid point; nobody Brown knows sits there and stares at the monitor

Shock if needed

Only done once every two minutes

Give medications

Only done once every three, four or five minutes depending on the flavour of your operation. We give adrenaline every four minutes so every second cycle

Gather a history

Grandpa fell down ....

Get a BGL and check other reversible causes

Last time Brown checked hypoglycaemia did not cause cardiac arrest, but your point about Hs and Ts is valid.

Confirm patency of airway, and if necessary move on to the next step, like intubation

Make sure ventilations are correct and adequate

What makes the Ambulance Officer or redneck volunteer firefighter/EMT ventilating the patient incapable of doing this?

Make sure compressions are correct and adequate

Now that is very important!

A cardiac arrest here might get three or four people (a normal crew + an IC or two crews where it would be nice if one was an IC but not essential). While somebody does CPR, we put in an LMA and then put the defibrillation pads on. At the end of the first cycle, check monitor and shock if required, go back to doing CPR. At some point about now somebody is going to shove in a drip and give some adrenaline. Repeat the pump-shock-adrenaline routine until you decide to cease resuscitation and go back to the station to watch telly.

We have been running cardiac arrests without intraosseous access since 1972 and have not found the little bit of time it takes to get a drip in to be that much of a problem.

 

[usalsfyre]

I choose the IO (and BIAD for that matter)option on pretty well all of my cardiac arrest. Why? Because it gives me loads more time to focus on ensuring compressions are effective and to get a history (i.e. search for reversible causes). In our system an airway must be established and ACLS must be in progress before we reach an outcome, one way or the other.

Most of you know I'm not big on being scared of a lawsuit. But the reality in the US is you must follow some sort of standard, even if it's not "protocol". At the moment that standard includes medications for cardiac arrest. I don't like it, I think it's a waste of time, but my opinion doesn't matter in this case. My kids like to eat and have a roof over their heads. As such, I continue to sling cardiotoxins around per advised in the appropriate ACLS algorithm

 

[usalsfyre]

What makes the Ambulance Officer or redneck volunteer firefighter/EMT ventilating the patient incapable of doing this?

Crap, half our paramedics can't do this effectively!

Typical first responder trying to ventilate a patient vs good airway control are two different things. If we didn't insist on blowing patients gastric systems full of air in arrest that'd be one thing, however the AHA decided in their INFINITE wisdom to keep the most difficult, least proven part of CPR for healthcare providers.

An aspiration makes these folks course a hell of a lot more complicated should their be an aspiration. BIADS have helped, but not fixed the problem.

 

[MrBrown]

Brown did not say medication should not be given in cardiac arrest just that the notion of "ZOMG WTF we have so many important things to do so lets forego putting a drip in and shove in an IO!" is a wee bit odd to Brown and our collective experience as there is plenty of time to put in an IV between the start and end of the second CPR cycle.

Oh and WTF is a BIAD?

 

[Shishkabob]

I'll combine your first few comments with a single response

Can be done in five seconds; if you do not carry the LMA then shove an oral airway in. One of your redneck volunteer firefighter/EMTs can do this

What the hell is with the redneck volunteer comments?

At some point, most cardiac arrests in Brown's experience this is not done until the second cycle of CPR or later as adrenaline is not given until at least the end of the second cycle.

This is a semi valid point; nobody Brown knows sits there and stares at the monitor

Only done once every two minutes

Only done once every three, four or five minutes depending on the flavour of your operation. We give adrenaline every four minutes so every second cycle

Grandpa fell down ....

You make it sound as if all that will just *poof* happen, without any effort being done. I don't know about you, but my patients don't call 911 with a King airway already in place when I arrive.


Establishing an airway, putting in a line, watching the monitor, giving medications, gathering a history: All stuff that has to be done. None of it is done prior to my arrival, and I'm the only person qualified at doing any of it. On top of that, no it's not "OMG GET THIS DONE", but there's no point in working a cardiac arrest if you're going to spend 15 minutes doing what can be done in 3.

Last time Brown checked hypoglycaemia did not cause cardiac arrest, but your point about Hs and Ts is valid.

Last time I checked, hypoglycemia not only COULD cause a cardiac arrest, but was also one of the Hs.

Not to mention, HYPERglycemia could cause acidosis which could cause cardiac instability.

What makes the Ambulance Officer or redneck volunteer firefighter/EMT ventilating the patient incapable of doing this?

So you're saying I should NOT make sure things are running smoothly?

Ever hear of the EMT student that makes up numbers because they can't obtain a BP?

A cardiac arrest here might get three or four people (a normal crew + an IC or two crews where it would be nice if one was an IC but not essential). While somebody does CPR, we put in an LMA and then put the defibrillation pads on. At the end of the first cycle, check monitor and shock if required, go back to doing CPR. At some point about now somebody is going to shove in a drip and give some adrenaline. Repeat the pump-shock-adrenaline routine until you decide to cease resuscitation and go back to the station to watch telly.

And I'll reiterate what I said before: I'm the only Paramedic on scene for most of my arrests. I'm the only one actually able to do more than squeeze a bag and push on a chest.

Sounds to me like you're spoiled with having multiple advanced level providers who each can work with eachother and split the tasks. Not always the case here. I like having a second Paramedic on scene with me in an arrest, but that's not always possible.

We have been running cardiac arrests without intraosseous access since 1972 and have not found the little bit of time it takes to get a drip in to be that much of a problem.

Funny, we've been backboarding patients without cause since the 70s... doesn't mean it's better.





I'll reiterate it: Codes are not hard to do, however that doesn't mean there isn't a lot to do, a lot to keep track of, and that I am often the only advanced provider on scene capable of doing the stuff.

 

[epipusher]

absolutely love the I.O. Our protocol is humerus only.

 

[Cawolf86]

We use an IO if we aren't successful in gaining peripheral access and the patient has no prior access (port/picc/etc).

 

[boingo]

Interesting point of view Brown. It is without a doubt faster to place an IO than an IV in the vast majority of patient, it is relatively large (15g) access, hard to dislodge (unlike an IV) and is so easy a caveman (firefighter, volunteer even) can do it.

Gathering a history should be more involved than "Grandpa fell down", PMH, meds, etc...are all vital to establishing possible cause and very well may help direct your care beyond Adrenaline every 4 minutes.

I quite often place an IV instead, but if any doubt, the IO goes in. I have no idea how many arrests you have worked since '72, but I can assure you I can remember pleny where IV access was difficult to near impossible, and I do a lot of them. Your mileage may vary.

 

[dixie_flatline]

And I'll reiterate what I said before: I'm the only Paramedic on scene for most of my arrests. I'm the only one actually able to do more than squeeze a bag and push on a chest.

Sounds to me like you're spoiled with having multiple advanced level providers who each can work with eachother and split the tasks. Not always the case here. I like having a second Paramedic on scene with me in an arrest, but that's not always possible.

Yeah, this is a big factor I think. Every code I've been on had at least 2 ALS providers and 5-7 BLS providers - and once it's a working code the EMS captain for that shift shows up. I was on a full code a couple months ago with 4 paramedics (granted, that was kind of a mess). For the most part our medics seem to just drop normal lines rather than use the EZ-IO.

 

[ah2388]

As much as I would like to disagree with Linuss...I can't say I disagree in this instance.

Senor Grandmaster El Bingeroso McMasterofMedicine Brown,
You mention employing assistance from 2 ambulances, 3 or 4 WELL TRAINED individuals including an absolute minimum of 2 "ALS" providers. In the rural situations which Linuss is describing, it is not uncommon for 1 ambulance to cover entire counties, or large scarcely populated areas. While this often times will make ROSC nearly impossible, with few codes actually being worked, the ones we do arrived at quickly leave a paramedic, an EMT, and usually several firefighters who are trained no further than the first responder level.

We could debate for hours about how the US system has a number of significant flaws, specifically the lack of division between fire suppression and EMS. The bottomline is, it's the reality here. These "redneck volunteer firemen" are unpaid, and joined the department in an effort to assist there rural community with an essential function for the protection of property. They did not join the community to assist on medical calls where they are often treated like 3rd world citizens by "paragods and ambulance driver's." With that being said, there is a huge training issue or lack there of in a lot of these people. Ignoring that, THEY ARE ALL WE HAVE. As such, while all the tasks Linuss listed are performed reasonably well by 1 provider, having worked in systems with multiple ALS providers similar to the system you described, it is certainly challenging to work a code effectively with only 1 person on scene with a reasonable level of training.

In conclusion,
I think that Linuss has a point here, establishing access quickly, with a tool that secures itself checks off one more thing off the list. In this situation,establishing access can often be one of the most time consuming things to do on a full arrest. To Linuss, don't be so defensive brother, if you know for yourself you are practicing good medicine, and have found a system that works for you...state so, backing it up with evidence you believe to be reasonable. Getting defensive about this type of thing would be like throwing blood in the water near the GBR...watch out for those brownsharks


Hopefully this wasn't long winded and made some sense, I am coming off a 48 without much sleep and I desperately need another nap

-Adam

 

[epipusher]

the patient has "access", regardless of the route. is that not the most important thing?

 

[Lady_EMT]

If the local redneck yahoo volunteer firefighters have shown up as well more the merrier.

I hardly appreciate your continuous references to us "dumb hick volunteers." I may be a volunteer in a rural setting, but I do a damn good job of doing what I need to do during a cardiac arrest.

If you want to talk about volunteers, please do it in a more respectable fashion.

Back on topic, I can't do IOs as I'm not a medic, but from what I've seen, they have their pros and cons. They seem quick, easy, and a good way to bypass the searching for IV access, but from what I've heard they're also very costly, so it's almost worth looking for IV access.



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[usalsfyre]

but from what I've heard they're also very costly, so it's almost worth looking for IV access.

This is an extremely poor reason to choose an IV over an IO. It's not a cost that's passed to the patient, they are there to use, so why are you worrying about it? If your service can't afford to pay, then they have no business playing.