Trouble with Ivs

[VFlutter]

One of which would be a peri-arrest patient your trying to keep from coding....

What are you basing your opinion of not needing to use IO access on?

Right. Because we arrive on scene before most of our cardiac arrest patients get around to coding.

That comment was phrased poorly, I was trying to make the point that you should not rely on IO access due to poor IV proficiency. Yes, if they are peri-arrest and have no viable IV access then go for the IO. But being able to secure IV access, even with difficult anatomy, is a key skill. In my personal experience few patients truly have no viable veins.

 

[SeeNoMore]

No offense, but what are you doing on these runs? CCT is a seperate sub-discipline that requires if not mastery than at least a strong base in paramedic level care. What are you considering to be CCT?

No offense taken. I don't mean to pretend I am some expert on critical care. Its als transport with vent pts and pts on drips. Its actually the only place I applied that called me back. We do backup for a more formal critical care and 911 hospital based service. So often pts are very ill and sometimes going long distances. I understand critical care is a specific field and ibreally enjoy it. I study a lot and have piles of books on cardiology rt critical care etc. But I see why you could object to me doing the job. I just hops 911 time will help me out.

Thanks everyone else for all the iv suggestions.

 

[usalsfyre]

In my personal experience few patients truly have no viable veins.

Which, no offense, is incredibly limited. There's also a difference between "no viable veins" and "no veins that will support what I need in the time it will take to access them". Finally, your used to working with backup, often not the case out-of-hospital.

Realistically an IO is less invasive than a central line. Yet I rarely see an issue made by nursing over centrals. What it really comes down to is comfort zone.

 

[TransportJockey]

I've spent two years as an EMT-I and now a medic for coming up on a year... I still have times I can't stick for crap. It happens. On the elderly, some times you might want to try not using a tq at all. I've gotten decent at not using one on elderly patients, especially those on Warfarin or with very fragile skin, and gotten good results.

As for big lines... in the past month I've started... 6, I think, 14g lines. 5 of those on real honest to goodness septic shock patients who I've given at least 2l of fluid to during transport. One of which wound up with a second line (20g) in his wrist so I could run dope after I ran in my 3L of NS.

 

[TransportJockey]

No offense taken. I don't mean to pretend I am some expert on critical care. Its als transport with vent pts and pts on drips. Its actually the only place I applied that called me back. We do backup for a more formal critical care and 911 hospital based service. So often pts are very ill and sometimes going long distances. I understand critical care is a specific field and ibreally enjoy it. I study a lot and have piles of books on cardiology rt critical care etc. But I see why you could object to me doing the job. I just hops 911 time will help me out.

Thanks everyone else for all the iv suggestions.

Hey one class I recommend if you can swing the cost is the Creighton Univserity distance learning CCP class. I'm doing it now because at my transfer service we run patients similar to yours, and as a new medic I wanted the extra education.

 

[the_negro_puppy]

Back to the OP-

Practice makes perfect. It took me just over a year of starting IVs to get really decent at them.

Vein selection. Spend extra time looking for suitable veins don't just compromise on the first you see.

Hand veins are easy to see but often hurt more and are more fragile. I go the forearm if possible. Still allows use of wrists hands and elbows.

Traction is under-estimated. always pulls the skin taught to allow proper penetration and prevent veins from rolling.

Tourniquets are not always necessary- today my student had 2 attempts on a 95 y.o with very visible veins. Both vein 'blew out" immediately. The pt's BP was 168/90 and with a tourniquet on the veinous pressure was high. I removed it completely and cannulated with ease.

- Dangle the limb, use gravity to engorge veins. The warmer the limb the better.

- I always insert the needle at the shallowest angle possible. Make sure when you get flash you advance the needle little bit more before you slide the catheter forward. The tip of the needle may be in but the tip of the cath may not be.

- If you are getting flash and can't advance you are most likely going through the other side of the vein. Go more gently. Other reasons are that you may be up against a valve or the wall of the vein. Try adjusting the direction of the cath or using saline to 'float' it in through a valve.

 

[ExpatMedic0]

It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.

not to "play the protocol call card" but going straight to IO in the case of cardiac arrest is written into many protocols.

If your the only ALS provider (and lets just assume your not one of the best at your agency when it comes to IV's), do you think taking extra time and possibly multiple attempts of placing an IV line on an obese dead person will out way the benefit? The person is already dead...

Can you show me some peer reviewed evidence or anything that would suggest that going straight to IO with a product like EZ-IO is less beneficial in cardiac arrest or ROC?

in terms of the OP. He/she is struggling with IV access, I think mentioning IO for a possible code situation is quite relevant to the topic

 

[SeeNoMore]

Certainly I would use an io if the need was there. I have placed two during my clinical ride time. So far the majority of pts who I wish to gain access on get an iv. I just want to reduce attempts made. I really appreciate all the tips.

 

[rwik123]

Can someone explain the "floating technique". My preceptor was trying to explain it to me as I was sticking a patient the other day and I just couldn't get it. Also the technique of using the flush to open valves to make advancing the cath easier.

 

[NYMedic828]

Can someone explain the "floating technique". My preceptor was trying to explain it to me as I was sticking a patient the other day and I just couldn't get it. Also the technique of using the flush to open valves to make advancing the cath easier.

Unlike arteries, veins have "valves." These valves are for the purpose of preventing the backflow of blood. They open only in one direction and they require pressure in that direction to force them open.

Blood does not flow through veins as simply as it does in arteries. Arteries receive direct pressure to move blood from the pumping action of the heart. By the time blood reaches post capillary venous circulation the pressure is mostly diminished and requires the action of skeletal and respiratory muscles to keep the blood moving. The valves essentially prevent the blood from moving backwards towards arterial circulation and heading in the direction of the heart.

The valves appear as little bumps on the veins. Unless it is your only available vein, it is best to avoid a presumed valve as it is like trying to push a firehose through a locked door. The only way you are going to get it through is with force, which causes damage and could blow out the vein.

What people are saying when they refer to "floating" is as follows:

When you insert your angiocath and get flash and all that good stuff, you go to advance your catheter and it seems to get stuck halfway. You presume you are "in" but you just can't advance the catheter, odds are you hit a valve. So at this point, you attach a flush to your catheter and attempt to flush the vein while advancing the cath in at the same time essentially "floating" it in and trying to force the valve open with the pressure of the flush. I would advise removing the VCB prior to attempting to float the catheter as well.

 

[Shishkabob]

It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.

And if I have a peri-arrest patient, they're getting what I can get in the quickest, which typically is an IO. As a corollary, it's far more important to obtain the IO then take the time searching for an IV after they arrest.


Drill 'em when you can prevent it, drill 'em when you can't.



As an aside, I brought in a hypotensive GI/Vaginal bleed to a level 1 trauma center not too long ago, and I was BARELY able to get a 22g in a hand vein. Some of the nurses did a friendly scoffing when they saw it... and proceeded to miss 4 sonogram guided IVs, 2 EJs, a femoral cut down, a foot cut down, and finally had to have a trauma surgeon do a central. The doc laughed saying "He did that bouncing down the road and you can't do it with her sitting here for 40 minutes?"

 

[NYMedic828]

And if I have a peri-arrest patient, they're getting what I can get in the quickest, which typically is an IO. As a corollary, it's far more important to obtain the IO then take the time searching for an IV after they arrest.


Drill 'em when you prevent it, drill 'em when you can't.



As an aside, I brought in a hypotensive GI/Vaginal bleed to a level 1 trauma center not too long ago, and I was BARELY able to get a 22g in a hand vein. Some of the nurses did a friendly scoffing when they saw it... and proceeded to miss 4 sonogram guided IVs, 2 EJs, a femoral cut down, a foot cut down, and finally had to have a trauma surgeon do a central. The doc laughed saying "He did that bouncing down the road and you can't do it with her sitting here for 40 minutes?"

If working an arrest I take a quick look at both arms and legs, look at the neck, if I see nothing I don't putz around with making them a pin cushion I go straight for the tibial EZ-IO. I wish we had humoral IO as studies have been showing it as equal efficacy to IV access. Hopefully we will have it at some point but we don't currently have the 145mm needles even if I wanted to do it.

Have to hear words from time to time as to why no IV attempt was documented and I went straight to using a $114 needle.

 

[Shishkabob]

If working an arrest I take a quick look at both arms and legs, look at the neck, if I see nothing I don't putz around with making them a pin cushion I go straight for the tibial EZ-IO. I wish we had humoral IO as studies have been showing it as equal efficacy to IV access. Hopefully we will have it at some point but we don't currently have the 145mm needles even if I wanted to do it.

Have to hear words from time to time as to why no IV attempt was documented and I went straight to using a $114 needle.

Yeah my medical director is not a fan of the IO and wants us to do the 90 second / 2 try thing "if there's time".

 

[NYMedic828]

Yeah my medical director is not a fan of the IO and wants us to do the 90 second / 2 try thing "if there's time".

Medical director doesn't care here.

Its the bosses who act like it comes out of their pocket.

 

[NomadicMedic]

I use an IO on every arrest. Nobody says anything.

 

[RocketMedic]

And if I have a peri-arrest patient, they're getting what I can get in the quickest, which typically is an IO. As a corollary, it's far more important to obtain the IO then take the time searching for an IV after they arrest.


Drill 'em when you can prevent it, drill 'em when you can't.



As an aside, I brought in a hypotensive GI/Vaginal bleed to a level 1 trauma center not too long ago, and I was BARELY able to get a 22g in a hand vein. Some of the nurses did a friendly scoffing when they saw it... and proceeded to miss 4 sonogram guided IVs, 2 EJs, a femoral cut down, a foot cut down, and finally had to have a trauma surgeon do a central. The doc laughed saying "He did that bouncing down the road and you can't do it with her sitting here for 40 minutes?"

I'd have EZ-IOed.

 

[RocketMedic]

I use an IO on every arrest. Nobody says anything.

Pretty much the same here. We can go humoral or tibial. I personally look for an amazing AC then go IO.

 

[Sublime]

I use an IO on every arrest. Nobody says anything.

Does anyone look for an EJ before going IO in an arrest?

 

[Sublime]

I use an IO on every arrest. Nobody says anything.

Anyone try for an EJ before going IO?

 

[Sublime]

Double post sorry ... iPad acting up