Intraosseous access in cardiac arrest.

[DESERTDOC]

Give a cursory glance at the patients neck looking for an EJ while I am at the head. If not, IO it is.

Always IO for PEDI code, no glance given, expressed or implied.

IO's for peds and adults are fast and mostly effective.

 

[Lady_EMT]

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.

Not my opinion. But many paid medics in my area take that account.


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[usalsfyre]

Not my opinion. But many paid medics in my area take that account.

And we wonder why the rest of healthcare doesn't consider us professionals...

Sorry, glad you came back and clarified the point.

 

[abckidsmom]

I think since the advent of EZIO, we have stopped looking for iv access at all in arrest, and go right for the drill. We could certainly take a second to look, cause I really believe that iv is quicker if you see an obvious site.

Brown, dear, you really need to realize that rural or not, good medics are rednecks too. Probably oughta find another stereotype, one that matters. K?

Anyways, I am too lazy to go on, I wills just say thanks to usuals for saying what I thought more intelligently. Im just typing this on my redneck phone, so im a little slow tonight.

 

[socalmedic]

I always look for an IV first. if i can get a 20 or larger i will go IV if all i find is 22-24 size veins then they will be getting an IO. I have had no problem gaining IV access and using a proper ETT for my airway as the only paramedic on scene. I use the IO and the King as they where intended, BACKUP, and yes i will admit freely that i have had to use both. but not before at least attempting IV/ETI.

 

[MrBrown]

I
Brown, dear, you really need to realize that rural or not, good medics are rednecks too. Probably oughta find another stereotype, one that matters. K?

Brown was taking the piss

 

[usalsfyre]

I use the IO and the King as they where intended, BACKUP, and yes i will admit freely that i have had to use both. but not before at least attempting IV/ETI.

Convincing evidence besides your personal belief is needed.

We've had this discussion before. The "tube of shame" BS needs to go away, ETI is NOT a "gold standard", an airway that delivers effective ventilation while providing reasonable protection from aspiration is.

15 years ago MAST were a "gold standard" too. How much time was spent off the chest attempting an ETT? Were you making sure compressions were of good quality while fishing around for a line?

 

[ah2388]

I always look for an IV first. if i can get a 20 or larger i will go IV if all i find is 22-24 size veins then they will be getting an IO. I have had no problem gaining IV access and using a proper ETT for my airway as the only paramedic on scene. I use the IO and the King as they where intended, BACKUP, and yes i will admit freely that i have had to use both. but not before at least attempting IV/ETI.

Another thing you may consider is that the EZ IO has a way of securing itself reasonably well. From your post I feel its reasonable to assume that you have been doing this for a minute..with that in mind, how many times have you yanked an IV out of a pt's arm while transferring them onto a spine board or into your ambulance?

 

[ah2388]

Convincing evidence besides your personal belief is needed.

We've had this discussion before. The "tube of shame" BS needs to go away, ETI is NOT a "gold standard", an airway that delivers effective ventilation while providing reasonable protection from aspiration is.

15 years ago MAST were a "gold standard" too. How much time was spent off the chest attempting an ETT? Were you making sure compressions were of good quality while fishing around for a line?

I think we can both agree that it is likely that compressions are neglected during attempts at ETI, however...assuming that this isn't the case, do you see any issues with ETI>King?

 

[DesertMedic66]

Another thing you may consider is that the EZ IO has a way of securing itself reasonably well. From your post I feel its reasonable to assume that you have been doing this for a minute..with that in mind, how many times have you yanked an IV out of a pt's arm while transferring them onto a spine board or into your ambulance?

That's the main reason I like to have a board under the patient before any lines get connected. People get a little crazy with shears and like to cut cords that we need (defib, leads, O2, any cord that is seen could be cut). I know it's not always possible to get a board under the patient before things start getting attached.

 

[ah2388]

That's the main reason I like to have a board under the patient before any lines get connected. People get a little crazy with shears and like to cut cords that we need (defib, leads, O2, any cord that is seen could be cut). I know it's not always possible to get a board under the patient before things start getting attached.

This is a good tip.

 

[usalsfyre]

I think we can both agree that it is likely that compressions are neglected during attempts at ETI, however...assuming that this isn't the case, do you see any issues with ETI>King?

Nope, and if I get a ROSC I tend to pull the King and intubate the patient if they have anatomy that is amicable to it. However, I've also used Kings on calls from start to finish, and can say in my limited, anecdotal experince I haven't seen anymore of an aspiration issue from a King than a ETT.

I think alot of the vitrol against BIADS is long on fear and short on fact.

 

[the_negro_puppy]

There are merits for both IV and IO but Brown does have a point about things to do in a cardiac arrest. Only ICP's have IO here so for us (paramedic/paramedic) or paramedic/student we don't have a choice until/if an ICP can attend. Having recently practiced running arrest scenarios, I can get an LMA in 2 minutes while partner applies pads and does compressions. Defib at 2 minutes, and get IV access in a few more minutes and have 3 shocks in and first amount of adrenaline by 7 minutes. I know this is vastly different to real arrests where more time is spent moving patients, suctioning airway etc

Having said that we dont intubate or use anto-arrhythmics or sodium bicarb at our level so Linuss does have a point in that he has more things to consider with a less skilled partner (EMT-B) who is only good for compressions andventilations.

 

[MrBrown]

Having said that we dont intubate or use anto-arrhythmics or sodium bicarb at our level so Linuss does have a point in that he has more things to consider with a less skilled partner (EMT-B) who is only good for compressions andventilations.

None of which we really use anyway; some arrests get intubated depending on the flavour of Intensive Care Paramedic you get but most have an LMA shoved down their gob

How you describe is pretty much how it works out in the real world here; somebody places an LMA pretty quick and starts ventilations while the other Ambulance Officer puts on the pads and does compressions.

It takes about 5-7 minutes for somebody else to get to the job and by this stage unless a family member is up to doing CPR we're not going to get past two to three rounds of CPR, a couple of shocks and an LMA but the evidence for doing more than that earlier on is pretty um, you know not there?

 

[Shishkabob]

15 years ago MAST were a "gold standard" too. How much time was spent off the chest attempting an ETT? Were you making sure compressions were of good quality while fishing around for a line?

I can honestly say my first ETI of a cardiac arrest was while I still had the FFs pump on the chest, and I got it first shot! I love the bougie.

 

[lawndartcatcher]

Our ALS service is taking part in a CCR pilot program (45% survival vs <5% national rate). Anyone in cardiac-caused arrest immediately gets (in this order):
1) CPR
2) O2 via NRB
3) Defibrillator attached
4) IO in a lower extremity (per the doc leading the study).

We don't bag or intubate cardiac arrests until we've done at least 3 cycles of CPR / shock / Epi; the NRM and chest compressions allow enough oxygen to diffuse into the lungs that you can maintain adequate SPO2. Because everyone else (including our exceedingly professional and well-trained volunteer EMT-Bs, thank you very much Mr. Brown) is busy up at the head / torso, using the EZ-IO in the lower extremity means we're not bumping into each other.

 

[socalmedic]

in bold

Convincing evidence besides your personal belief is needed. dont have it, the OP asked what I do and I posted that. where I am the king is a rescue airway and is listed as such, to boot it can only be used after two failed attempts at ETI. as you requested in the past I am still trying to get my docs report on our trial of IO/KING as front line in an arrest which was never used again after the trial for reasons that have been previously discussed. I haven't forgotten to get the report for you, it should be out in February as we are apparently using 2011 data for the stats in addition to 2009 data.

How much time was spent off the chest attempting an ETT?
None, only once have I paused compression for sake of intubation.

Were you making sure compressions were of good quality while fishing around for a line? absolutely, doesn't take but a few second of concentration to get a line, the rest of the time getting ready, line striped, tourniquet on... i can watch everything that is going on. besides my EMT partners are pretty good at thumping the chest.

@ah2388 never have I had a line pulled out during transfer. as fire... said I put them on a LSB very early on. and i keep all the wires and lines on one side of the patient which makes rolling easy. once on the board the monitor gets placed on the legs (which is right where the IO would be...) with the wires neatly under all the straps. iv bag becomes the only thing not strapped to the same unit as the patient. I also use a saline lock for all IV starts so I can detach the bag when needed for transfer. at the hospital the IV gets detached, and the whole LSB/patient/monitor/wires package gets moved to the hospital bed and they place their pads and take mine off. IV gets re-attached after my monitor and wires are out of the way.

 

[MrBrown]

(including our exceedingly professional and well-trained volunteer EMT-Bs, thank you very much Mr. Brown).

Somebody really needs to learn what taking the piss means

What you describe is more-or-less towards our priorities here: rapid and continued CPR and defibrillation.

It is nice to put a drip into the bloke and give him some adrenaline but by far CPR and defibrillation take priority.

 

[Shishkabob]

It is nice to put a drip into the bloke and give him some adrenaline but by far CPR and defibrillation take priority.

And neither of which I typically do on an arrest, and neither of which is delayed while doing an IO which takes seconds, in the leg, away from the chest.


Which brings me back to wondering why you are against IOs in the onset.

 

[MrBrown]

And neither of which I typically do on an arrest, and neither of which is delayed while doing an IO which takes seconds, in the leg, away from the chest.

So if you have somebody else doing your CPR and defibrillation, why can't you take the time to put an IV into this patient?

You've never put an IV into some blokes foot?

Which brings me back to wondering why you are against IOs in the onset.

Brown is not against IO as a means of circulatory access in a cardiac arrest; but it should not be first choice because there is really no valid reason you cannot at least attempt an IV first, shove a 14ga. into his external jugular if you have to.

We have been running cardiac arrests without intraosseous access since the Mobile Intensive Care (Life Support Unit) pilot project was introduced in 1972 and have not found it to be such a problem that we needed to introduce intraosseous access in the adult patient any sooner than when we did (2009).

The following is the advice of the Medical Directorate of the London Ambulance Service regarding intraosseous access (source)

The EZ IO should never be used ...where there is an appropriate alternative route for a drug ... for patients in cardiac arrest the EZ ;IO should only be used when two attempts at peripheral access and one attempts at external jugular vein access has been unsuccessful.

Brown supposes that the consensus view here, in AU and the UK is that its just not that important and to routinely drill an IO into some blokes leg is a bit of overkill.