IO contraindications.

[Aidey]

I used to work as a dialysis tech, so I have a bit of an insiders view on the whole thing. Honestly, if we are doing IVs properly in the field, it isn't much different than accessing a fistula in an outpatient dialysis clinic. The biggest difference is the amount of PPE the dialysis techs wear, which includes a face shield and disposable lab coat.

I personally am more apt to go fistula (or catheter, or Picc line) before IO in a chronically ill patient. If some sort of vascular access is already present, I'm not really sure I want to go sticking a needle into someone's bone. If something goes wrong, the first words out of the lawyer's mouth in trial will be "Why did you do this when you already had a route of vascular access".

I've spent the last 2 days trying to find EZ IO studies done on patients with pre-existing conditions, like diabetes, or kidney failure, or different degrees of osteoperosis and I can't find a single one. All the ones I've found don't specify what the participant's underlying health status was.

 

[So. IL Medic]

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?

My first reaction was to admin glucagon IM while you debated to IO or not to IO....

Then if this hypothetical pt worsened towards arrest number four, then go with the IO. Any complications would be easier to treat than death.

Unfortunately around here, any attempt to access a fistula or graft would land you in the med director's office as we don't have the training for such access. Side note - we just got the system to consider port access training.

 

[So. IL Medic]

If something goes wrong, the first words out of the lawyer's mouth in trial will be "Why did you do this when you already had a route of vascular access".

"Because our protocols don't allow accessing that route." Easy enough.

 

[Aidey]

Our protocols do allow it if it is an "emergent" situation. If it wasn't allowed it would be that easy.

For glucagon to work it requires the pt to have sufficient stores of glycogen, what are the chances a person that sick would have sufficient stores?

 

[MissMedicCMO]

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?

Thats all my service carries too. They say they can be used on adults but not likely on a healthy adult. I had a 15y/o/f, traumatic arrest who had no IV access what so ever...Attempted an IO 3 freakin times and everytime the needles bent..they are not designed for a stronger healthier bone. I even checked with my ems director to make sure I wasn't doing something wrong..but he said no..they aren't meant to do adults really...and my fellow co-workers have had the same problems...

On that note..our protocols are pretty much the same as everyone elses as far as fx and edema...osto etc etc

 

[So. IL Medic]

Our protocols do allow it if it is an "emergent" situation. If it wasn't allowed it would be that easy.

For glucagon to work it requires the pt to have sufficient stores of glycogen, what are the chances a person that sick would have sufficient stores?

True, glucagon stimulates glycogenolysis as it's primary action. However, two things to consider. One, it typically takes two to three days to deplete glycogen stores with normal activity enough for ketone metabolic pathways kick in as a supplement. Two, as glycogen stores deplete, pyruvate begins to be converted though a process similar to gluconeogenesis. Non-hepatic tissue lacks glucose-6-phosphatase and so the glucose-6-phosphate becomes a substrate for glycogen production. Essentially, it takes a long time to completely deplete glycogen stores.

If a patient had absolutely nothing p.o. for a couple of days, they would still have enough glycogen for some elevation of glucose but I would agree it's effectiveness would be decreased. Longer than that then there would be other issues to worry about.

 

[Aidey]

What type of IO were you using?

That is in a healthy patient though, what about someone as sick as the hypothetical patient from above? Glucagon also takes time to work, what is to say the patient wont code in between administering it and waiting for it to kick in?

 

[redcrossemt]

What type of IO were you using?

We use the Jamshidi and I've bent a few on adults... You have to be reeeeal slow with them.

 

[Jeffrey_169]

In Amarillo TX we have a drill type IO system, and there are so few contraindications because if a pt is that bad off and they need the infusion that badly, there are few things taking presidence over it. In our system if a pt. gets an IO they circling the drain and they despirately need it.

 

[grich242]

We use the BOne Injection Gun (B.I.G.) and it works great but placement is slightly modified and glucose while not "officialy" contraindicated but the 1 med discouraged via io unless its a last resort.

 

[Aidey]

Thats all my service carries too. They say they can be used on adults but not likely on a healthy adult. I had a 15y/o/f, traumatic arrest who had no IV access what so ever...Attempted an IO 3 freakin times and everytime the needles bent..they are not designed for a stronger healthier bone. I even checked with my ems director to make sure I wasn't doing something wrong..but he said no..they aren't meant to do adults really...and my fellow co-workers have had the same problems...

On that note..our protocols are pretty much the same as everyone elses as far as fx and edema...osto etc etc

We use the Jamshidi and I've bent a few on adults... You have to be reeeeal slow with them.

We have the EZ IO, so that isn't much of a concern.

 

[redcrossemt]

We have the EZ IO, so that isn't much of a concern.

Yes, the EZ-IO, FAST, and BIG are all great access devices.

 

[Aidey]

I'm not as fond of the FAST 1 as the others, mostly because it puts the IO up in the middle of all the action, rather than down in the leg. I like being able to get an IO and give all the drugs without getting in the way of people doing compressions or managing the airway.

 

[jonmedic101]

B.i.g

hey

I am an Israeli paramedic, and i am using the B.I.G repetedly for every situation i need an immidiate vascular access and don't have the time to search for veins.
i gave Glucose throgh the BIG several times. when i got my training for using the deivce from the manufactorer, i realized that we can give aNY medication throgh IO, including Glicose. if you dilute it to 25% as required there is no different that an IV.
extravasation? if you penetrate in the appropriate location, this will never happen with the BIG, since the penetration is automatic and VERY fast- 0.something seconds. this may happen if you use the munal devices of the driller.
this is one of the reasons i prefer the BIG.

Jonmedic101

 

[lightsandsirens5]

We use the Jamshidi and I've bent a few on adults... You have to be reeeeal slow with them.

We use those too, but we should be switching to the drill pretty soon here.

~~~~~~~~~

From my state. EMS protocols:

II. Contraindications
A. Pt older than 6 yrs.
B. IO line should not be inserted if there is a known fx in the bone chosen for line placement
C. IO should not be placed in when there is an infection present in the leg chosen for placement. (Ie. Cellulites)
B. Do not attempt insertion twice in same limb.

County protocols:

Same as state, except we can use IOs on adults as well as infants and children. For critical children, we get 90 seconds to establish an IV line. If we cannot get in we go with the IO. For critical adults we get two or three tries on an IV, if we can't get that we do the IO.

 

[FLEMTP]

Seems like most agencies have the same absolute contraindications.

We have the ability to use the IO however we see fit, conscious or not. Granted, inability to establish IV access in a patient is not a good reason to drill someone... we typically reserve it for critical patients..conscious or not. Conscious we have the ability to push lidocaine, which is the appropriate and humane thing to do... and versed should the need arise and the lidocaine isnt cutting it alone.

We also have the ability to place a central line (subclavian) should the need arise. It is no longer covered in our medical guidelines, but we also have the ability to do whatever we deem medically appropriate for the patient so long as we can justify it to the Medical Director after the fact. The frequency of a central line is very minimal now with the IO, but there are still patients who could and would be a candidate for one in the field...especially those with the contraindications to the IO

I also want to add this, because im sure some people will wonder about our term of the guidelines vs protocols and what we can and cannot do.

In our agency there is no reason for us to contact medical control at all. We are expected to have appropriate knowledge to treat the patients we see, and also the MD's in the ER really have no idea what we are capable of doing, or which medications or equipment we carry. I have on occasion, consulted a Doctor in the ER prior to providing certain treatments when a condition presents that I have limited knowledge in... but nothing says that I HAVE to follow any of the doctors orders if he tries to give me any, especially if I disagree with them. We work under the authority of our Medical Director, not the Doctor in the ED.

 

[Flight-LP]

I'm surprised no one mentioned an AKA as being a contraindication. Seems it would be one if you are only authorized one insertion site...............

The inability to located landmarks is a poor contraindication. The EZ I/O after all can be inserted in one of 3 locations and they make a longer needle for those grossly obese. I have yet to not be able to place one due to anatomy issue or excessive adipose tissue. It can be done, perhaps you should review current literature and trends in intraosseous care.