IO vs IV for cardiac arrest: recently published research

[CALEMT]

I remember my preceptor saying when he took a class on IO's a humoral head IO was better that a proximal tibia IO in the case of a full arrest. The reasoning per the instructor of the class is because it's closer to the heart, makes sense but I haven't researched it at all to confirm that is in-fact the case. As for IV vs IO I go for the IO, just because I can establish vascular access faster which in return I can get medications on board faster.

Personally I don't think there is a difference between IV vs IO. Out of the 8 full arrests I've had one person who I got ROSC on. I don't believe this is because of the fact I started a IO over a IV. I believe its because of outstanding by stander CPR prior to our arrival and early defibrillation. The 7 other arrests were unwitnessed with no CPR PTA.

 

[EpiEMS]

Narcan has not been shown to help in cardiac arrests and was removed from ACLS full arrest guidelines

The 2015 ACLS guidelines say: "We can make no recommendation regarding the administration of naloxone in confirmed opioid-associated cardiac arrest. Patients with opioid-associated cardiac arrest are managed in accordance with standard ACLS practices."

No RCT says that naloxone doesn't help, as far as I know. One small prospective study weakly suggests it may help.

In principle, seems like you're right.

The reasoning per the instructor of the class is because it's closer to the heart,

Why not sternal?

 

[Harrison Phord]

I mean the study does look at around 20 times as many IV patients as IO patients - compounding it, the IO patients generally had non-shockable rhythms, non-cardiac etiologies, and were unwitnessed. So yeah, of course the IV patients are going to have better outcomes looking at that alone.

 

[Summit]

@EpiEMS I hate those sternals... they were a good idea for battlefield where the patient is on the ground. Trying to get them on a hospital bed?

I mean the study does look at around 20 times as many IV patients as IO patients - compounding it, the IO patients generally had non-shockable rhythms, non-cardiac etiologies, and were unwitnessed. So yeah, of course the IV patients are going to have better outcomes looking at that alone.

The studies said they had adjusted multivariate analysis... but that doesn't mean the adjustment was sufficient. The fact that parenteral meds intracode (the actual intervention, if not the independent variable, when looking at a dependent variable like ROSC) of are not thought to be effectatious points that this is a selection bias improperly compensated for, or, some other lurking variable problem.

 

[FiremanMike]

I don't personally understand the rationale behind narcan in cardiac arrests. If we did have a cardiac arrest due to an opiate, it would have been directly caused by the respiratory depression leading to hypoxia, which we have fixed by advanced airway placement and good oxygenation...

 

[EpiEMS]

I don't personally understand the rationale behind narcan in cardiac arrests.

No disagreement there. These folks briefly list 2 possible mechanisms:

"The interest in the utilization of naloxone in the non-overdosed opioid cardiac arrest patient stems from many hypotheses, one being that endogenous opioids are felt to have a myocardial depressant effect with a lowering of systemic blood pressure. Alternatively, naloxone may stimulate catecholamine release and increase sympathetic nerve activity significantly elevating heart rate and blood pressure."

 

[StCEMT]

The last two people I drilled were unwitnesswd arrests and rather large. IV wouldn't have changed much there.

 

[Summit]

Narcan was gonna be the miracle drug for sepsis, shock, and codes except the studies showed it wasn't... a long time ago.

Hey now we are waiting to see if Marik's ascorbic acid, thiamine, and steroid cocktail is the bees knees for sepsis...

 

[EpiEMS]

Hey now we are waiting to see if Marik's ascorbic acid, thiamine, and steroid cocktail is the bees knees for sepsis...

Color me skeptical. Without an RCT, we shouldn't jump on this one. (And steroids, eh, doubt they help.)

 

[cruiseforever]

From my experience ROSC pts. get more IVs because of AEDs or first shock conversion from us. IOs are the first line access for us if one remains in cardiac arrest..

 

[Colt45]

Well logically, it makes sense.

For someone without a pulse, who is receiving cpr, which do you think is going to perfuse better? An EJ which is close to their core? Or a tibial io? When doing good CPR are you more likely to feel a carotid pulse or a pedal pulse?

In all honesty, I feel most providers assume they won't be able to find a line so they go for the IO. We try IV access before going to the IO and I would say 80% of the time, an EJ or other vascular access ( AC, etc) is easily obtainable. Have someone push on their liver while someone is doing CPR and they will almost always pop right up. And they don't fight the EJ either, so it's the easiest line ever.

Can you or someone please elaborate a little more on the liver pressure thing? Why would this be more beneficial than a tornoquet on the extremity? It's late at night and this caught my eye. It's a simple anatomy answer but my question is really more why is it going to produce better results than a tornoquet?

 

[CALEMT]

Can you or someone please elaborate a little more on the liver pressure thing? Why would this be more beneficial than a tornoquet on the extremity? It's late at night and this caught my eye. It's a simple anatomy answer but my question is really more why is it going to produce better results than a tornoquet?

Can’t use a TQ when you’re going for an EJ (external jugular). Kinda hard to put a TQ around someone’s neck.

 

[DesertMedic66]

Can’t use a TQ when you’re going for an EJ (external jugular). Kinda hard to put a TQ around someone’s neck.

It’s not hard to put a TQ around someone’s neck... it’s just generally frowned upon.

 

[CALEMT]

It’s not hard to put a TQ around someone’s neck... it’s just generally frowned upon.

Touché

 

[COmedic17]

Uhhhh.... narcan and dextrose aren’t cardiac arrest drugs..

You don't give Nathan to known heroin od arrests?

Or dextrose when they are hypoglycemic? I feel like you probably do.

 

[reaper]

You don't give Nathan to known heroin od arrests?

Or dextrose when they are hypoglycemic? I feel like you probably do.

Once you achieve ROSC, then you worry about the dextrose. Giving it during the arrest went out years ago.

 

[StCEMT]

Can’t use a TQ when you’re going for an EJ (external jugular). Kinda hard to put a TQ around someone’s neck.

Secondary use for a stethoscope amigo. Just enough pressure to add a little more size to an EJ

 

[Colt45]

Can’t use a TQ when you’re going for an EJ (external jugular). Kinda hard to put a TQ around someone’s neck.

Lol I realize that I was referring to an extremity. I'm pretty sure I even said that in my post.

 

[DesertMedic66]

You don't give Nathan to known heroin od arrests?

Or dextrose when they are hypoglycemic? I feel like you probably do.

Negative on both accounts. Why would I give narcan? What process from a opiate OD kills this patient and what are we already doing during CPR for that issue? Narcan is not going to magically make your cardiac arrest patient start breathing.

BGL isn’t checked during the codes I run. If I get pulses back then their BGL will be checked and hypoglycemia will be treated from that point on. BGL checks are not accurate during cardiac arrest.

There is zero evidence that either of those medications are helpful (with evidence of dextrose actually being harmful).

Helpful links, your patients may thank me: https://www.ems1.com/cardiac-care/a...rose-during-cardiac-arrest-improves-outcomes/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415309/ (Same study as above, just a NCBI link)

http://millhillavecommand.blogspot.com/2012/03/using-dextrose-in-cardiac-arrest.html?m=1

http://roguemedic.com/2015/01/narcan-in-cardiac-arrest-safe-as-long-as-i-dont-understand-safety/

 

[VFlutter]

First of all, I think pressing on someones liver during CPR is a horrible idea. Many patient's body habitus prevents EJ access. And a Humeral IO is pretty much as close to central access as you can get.