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Have you ever done IO IV Placement?

Nurses   (13,986 Views 11 Comments)

UM Review RN is a ASN, RN and specializes in Utilization Management.

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Where's the best location to choose? What gauge needle? How deep? Aspirate for blood return? How much flush and how often?

Try for an IJ first?

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DarrenWright specializes in Cardiac Surg, IR, Peds ICU, Emergency.

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Done many.

It depends on the patient (adult or pediatric), the needle type, and the urgency.

If you are using the traditional Jamshidi trocar on a pediatric (or even an adult), you will put it in the proximal tibia...sort of just medial to and below the knee. You will hold the needle firmly in your dominant hand, stabilize the extremity and the skin, and 'drill' into the bone going as straight with the needle as you possibly can. You will almost always 'feel' a pop as the tip of the needle stops meeting resistance and enters the medullary cavity, and you stop...that's how deep you go. I think the standard IO needle guages are around the 15 and 17 gauge variety...again, depends on the brand. You can let go of the needle, and the needle will stick straight up and hold itself reasonably in place.

You only need to aspirate enough to confirm placement, and sometimes even a successful placement will not provide any aspirate. If you don't get aspirate, but think you are in the right place, you can slowly infuse some crystalloid and see if the area around the puncture and on the back of the puncture site shows any swelling or increasing firmness.

Some needles are very specific; i.e. the FAST brand IO is designed for adult sternal placement. Very easy to use, but a brutal looking tool. The EZ-IO is like a drill; the manufacturer provides a video of unmedicated adult volunteers who get an IO placed by the EZ IO gun into their leg, and they said it was very tolerable. They said the infusion of fluid was more uncomfortable than the actual placement of the needle.

I think an IO is easier to place in an emergent situation than an IJ, but I would at least probably look and maybe try to place and External Jugular line before putting in an IO...but this decision should take less than a minute.

Lots on google.

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1 Article; 15,699 Visitors; 1,905 Posts

My employer currently uses both the adult and pedi BIG. In addition, the sternal IO FAST and good old jamshidi (sp?) are utilized.

Aspiration of marrow will often not be possible. You can feel a pop and lack of resistance if you are using the older devices. You should be able to flush. Watch for swelling. If using the tibial plateu, monitor the posterior aspect of the lower leg. (calf swelling)

Each site has advantages and disadvantages. Every site has advantages and pitfalls. For example, the tibial plateau would be a poor choice in a patient with crushed legs, while a patent who sustained a sternal fracture from smashing into a steering wheel would not benefit from the FAST.

We do not perform internal jugular punctures.

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scattycarrot has 10 years experience and specializes in ITU/Emergency.

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As far as i aware the AHA teach IO access if you cannot get periperal in an emergency situation. One reason is that IO is not contraindicated in coagulopathy.

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EDValerieRN is a ASN, RN and specializes in ER, Peds, Charge RN.

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You can also use a regular large-bore needle (18g or bigger) if the poop hits the fan. We use Jamshidis on the kids, and we just got the IO drill (forget the name, think it's called EZ-IO) on the adults. If you've taken PALS, it feels a lot like the chicken bone, only with less resistance after the pop.

Depending on the situation, I don't think I would mess around too much trying to get a line.. the rule of thumb is three tries or ninety seconds, and then give 'em an IO.

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Dolce specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

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I just finished the ACLS refresher course and the new AHA guidelines specify making two attempts at IV access and then proceeding directly to IO. I've personally never done IO access.

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1,805 Visitors; 35 Posts

I have never placed one. I do know at my facilty the paramedics have placed them during emergent situations as many of our clients will be very difficult to get IV access on. I personally think its the greatest thing since sliced bread, and where i work, could easily be a matter of life or death. I think our nurses should be trained as it is at least a 20 minute wait for paramedics to arrive. I think the first few times would be scary but then as with any skill, once you are competent you have the opportunity to truly make a difference.

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Really depends on the situation. I am not sure about a code. (At least the first several minutes.) Since medications in an arrest really do not improve outcomes, having access to give something that does not work is suspect IMHO.

As far as the two to three try rule, I think we still need to use common sense. Obviously, if you have a patient who is not acutely de-compensating, perhaps it would be better to take some time and look for a peripheral site.

The situations I see the utility of IO access are critical patients who require interventions that involve medication delivery. I have only placed two IO devices; however, both were in the field on patients where access was needed for RSI and peripheral access had already been attempted.

My fear with this technology is that people will push to place these devices on patients that may not require IO access. A good tool when used appropriately; however, placing it next to sliced bread or the wheel?

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romstead has 30+ years experience and specializes in CRITIAL CARE TRANSPORT AIR AND GROUND.

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Just put one in yesterday.. on a 10wk old. I used a EZ-IO pedi 15g needle..color code (pink) in to the tib. plat-o . it went in great. I like to incert my needle in through the tissue and palp the borders of the bone then center the tip and then hit the drill. we aspirated about 8ml of bood for labs then hooked up a pump and then gave 2 mg of 2%lido for comfort. as rapid infusion on the pump can be painful.. the key is to secure the site very well and lash the feet together so the pt will not kick the I.o. site.. and watch the site for leaking..we have also found using a adult needle is better if you have a lot of tissue mass between the bone and the skin surface..as it is better to back out a bit in to the medually cavity or hollow part of the bone than to have a short needle pushed out of the bone with infusion pressure and movement..

Rob

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usalsfyre has 8 years experience and specializes in CCT.

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I've been using the EZ-IO for close to five years now, I've probably done close to 50 of them. Currently first-line access for cardiac arrest at our prehospital service. Far faster than a central line, probably faster to place than a peripheral line, and incredibly easy to place. EZIOs are 15ga for adult and I believe 18ga for a pediatric patient. Drill it in to the hub, you will know when it's in (feels like sinking a screw) Flush with 10 mls of saline and go to town. Two sites are approved, humeral head and tibia.

It is more invasive than an IV though, so it should probably be restricted to emergent use. They also must be removed at 24hrs so central access will have to be placed post-emergency.

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romstead has 30+ years experience and specializes in CRITIAL CARE TRANSPORT AIR AND GROUND.

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yep I love them. I am working in a small native american clinic as a paramedic with expanded scope, I have put more than I can count. they are fast and not as bad as sticking some one over and over no one wins if you pt is a pin cushion at the end of day.. I say get it done and get it done the first time. for cased that really need a line.. I think most providers are just not use the ease and saftey of I.O.. I say get over it..

ROB

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