IO contraindications.

Aidey

Aidey

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In our protocols there are very few listed contraindications to IO. I've been thinking more lately about some disease processes and their affects on the body, and if we really want to IO those people. People with things like osteogenesis imperfecta, bone cancer, osteomyelitis, dwarfism (anatomy/growth plate differences). What about people with things like severely uncontrolled diabetes who have poor healing times or people with kidney disease who have poor bone density because of calcium leaching?

So here are my questions, are any of these conditions contraindications for IO access in your system? What contraindications have you been taught? Should any of these be contraindications?
 
None of those are absolute contraindications where I work, but mostly because IO is only prior to contact for critical peds and adult full arrest. conscious IO placement requires a base station order.
 
Copy Pasta from our protocols:

Everything in our protocols are standing orders except what is in the medics controlled drug kit.

Indications
► Adult patients age ≥ 8 and/or 40 kg or greater
► Intravenous fluids or medications needed and a peripheral IV cannot be established AND exhibit 1 or more of the following:
An altered mental status (GCS of 12 or less).
Respiratory compromise (SaO2 80% after appropriate oxygen therapy, respiratory rate < 10 or > 40 per minute.
Hemodynamic instability (Systolic BP of < 90).

Contraindications
► Fracture of the tibia or femur (consider alternate tibia)
► Previous orthopedic procedures (IO within 24 hours, Knee replacement) (consider alternate tibia)
Pre-Existing medical condition (tumor near site or peripheral vascular disease).
Infection at insertion site.
Inability to locate landmarks due to significant edema.
Excessive tissue at insertion site
 
Last edited by a moderator:
Dominion said:
Copy Pasta from our protocols:

Everything in our protocols are standing orders except what is in the medics controlled drug kit.

Indications
► Adult patients age ≥ 8 and/or 40 kg or greater
► Intravenous fluids or medications needed and a peripheral IV cannot be established AND exhibit 1 or more of the following:
An altered mental status (GCS of 12 or less).
Respiratory compromise (SaO2 80% after appropriate oxygen therapy, respiratory rate < 10 or > 40 per minute.
Hemodynamic instability (Systolic BP of < 90).

Contraindications
► Fracture of the tibia or femur (consider alternate tibia)
► Previous orthopedic procedures (IO within 24 hours, Knee replacement) (consider alternate tibia)
Pre-Existing medical condition (tumor near site or peripheral vascular disease).
Infection at insertion site.
Inability to locate landmarks due to significant edema.
Excessive tissue at insertion site
Click to expand...

Eeek, those last two scare me! Does your service not provide you guys with the LD size?
 
Even if you have the long needles you still can't do an IO if you don't have landmarks.

Do you guys think any of those listed conditions should be contraindications? Or any other conditions I didn't mention?
 
Aidey said:
In our protocols there are very few listed contraindications to IO. I've been thinking more lately about some disease processes and their affects on the body, and if we really want to IO those people. People with things like osteogenesis imperfecta, bone cancer, osteomyelitis, dwarfism (anatomy/growth plate differences). What about people with things like severely uncontrolled diabetes who have poor healing times or people with kidney disease who have poor bone density because of calcium leaching?

So here are my questions, are any of these conditions contraindications for IO access in your system? What contraindications have you been taught? Should any of these be contraindications?
Click to expand...

I was taught that osteogenesis imperfecta, bone cancer, and osteomyelitis were contraindications.

We didn't hear about kidney disease, dwarfism, etc. but it would be a clinical judgement call with any of these patients. When I'm to the point of IO access, it's typically a life or death situation and I've already decided peripheral access isn't going to happen.
 
Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.:P
 
atropine said:
Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.:P
Click to expand...

Oh yeah... I forgot. There's never any ROSC is Southern Cali. ;)
 
atropine said:
Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.:P
Click to expand...

Glad to hear that only corpses would be the recipient of those procedures on your watch.
 
atropine said:
Who cares if your using an IO, your patient is probably dead. Same thing with the ET tube if your usnig one your pt is probably a goner.:P
Click to expand...

Yeah, and obtaining a patent IO in an unstable patient isn't important.
 
vquintessence said:
Eeek, those last two scare me! Does your service not provide you guys with the LD size?
Click to expand...

My service only carries the shorter 'pediatric' versions. For adults we have IV > EJ > Tube. I'm extremely tired and I can't place LD. What are you meaning by that?
 
I'm not talking about "dead" patients, where the IO is the last ditch effort. I'm curious about patients who are likely to live but who need an intervention ASAP to keep it that way. Pre-hospital IO started out as a end of the line intervention, and I think a lot of us were taught that trauma to the bone or inability to palpate the landmarks were the only contraindications because the pt was likely in arrest anyway. Now that it is being used more in other types of patients, I'm wondering what other contraindications we need to be thinking about.

What I would really like to do is find out if the EZ IO has been studied in anyone besides healthy people, and what they have found.

In our protocols we are allowed to use IO in any "critical" patient that needs vascular access for medication or fluid administration. This includes hypoglycemic patients, anaphylaxis patients (if you need to RSI or give them fluids), anyone who qualifies for RSI and there is no IV, among others.
 
IO devices

hey fellows,

what do you use for IO in your EMS?

jonmedic
Paramedic from the Israeli EMS
 
Aidey said:
What contraindications have you been taught? Should any of these be contraindications?
Click to expand...

The only hard and fast contraindications we have is the universal fx at or above the IO site and infection, like cellulitis at the IO site. Caution with severe osteoporosis is included.

Otherwise the greater concern is that if you are grabbing for your IO setup then the patient must require vascular access quickly so there are more immediate issues to worry about than calcification.

Moreover, more systems are expanding IO sites to include all "long bone" areas - tibia, illiac crest, sternum, humerus.
 
What I'm trying to work out is a "what is better" when you have a patient with no IV access, and you are forced to choose between an alternative access and IO, or no access at all. For example a dialysis patient, or someone with a PICC line for cancer treatment, or an indwelling sub-clavian cath.

Obviously these are going to be rare situations, which is why I think we don't really discuss them when addressing IO access. In an OI patient they may not have a fracture of the long bone now, but inserting the IO could cause one.

Say you have a 40 year hypoglycemic patient with known Type 1 diabetes that has been very poorly controlled. She is unresponsive and currently reading "low" on the glucometer. The pt has a history of going into cardiac arrest 3 times this year secondary to hypoglycemia because vascular access is so difficult on her. The pt is mostly blind, has a L AKA post osteomyelitis a couple of years ago and has been on dialysis for the last several years. The pt also tends to be non-compliant with her renal diet.

This is a patient who doesn't heal well, likely has osteoperosis, or decreased bone density, a history of amputation from a bone infection and is really not someone you want to wait to give sugar too because of her history to go down fast. What is better, sticking her fistula or giving her an IO?
 
Aidey said:
This is a patient who doesn't heal well, likely has osteoperosis, or decreased bone density, a history of amputation from a bone infection and is really not someone you want to wait to give sugar too because of her history to go down fast. What is better, sticking her fistula or giving her an IO?
Click to expand...

Wow... Uhm... That's no good. I guess I would try a couple sticks at peripheral access including looking for an EJ, and then go to IO and be careful about cleanliness. Sticking a fistula is always a bad thing... This patient's fistula going bad would be very detrimental to her outcome.
 
Why do you say sticking a fistula (or graft) always a bad thing?

Obviously, if you mess it up it is a bad thing, but it's designed to be stuck by needles.
 
Aidey said:
Why do you say sticking a fistula (or graft) always a bad thing?

Obviously, if you mess it up it is a bad thing, but it's designed to be stuck by needles.
Click to expand...

Never say always, right?

I think it's something that we can look to as a last resort, but something that should never be taken lightly. The complications of an infection or mess up can be devastating to the patient, requiring placement of a temporary dialysis catheter (and changes of that), while they try to get another fistula to take (which can take many months - if they can even do another one). These are typically accessed in much cleaner and controlled conditions than we have to work with. Remember, the patient may die without dialysis access.

At the same level, you have to weigh the risk factors of the fistula versus the risks of the other access (IO), and compare these to the benefits of access in your patient. I think I would personally attempt IO first, but would go on to the fistula (with medical control orders in my system) if the patient was critical.
 
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