I/O Access in hospital-Code Blue or RRT Protocol?

in2bate71, BSN, RN · Oct 1, 2009

If you haven't done so yet, go to the Vidacare website and see if any of the info there will help you. I use the EZ-IO at both the flight service and the ED I work at...absolutely a must-have in my opinion. The company produces a training manual to help guide you, and the reps, of course, are willing to come out and help. (Obviously there are other companies out there, this is just the one I'm most familiar with).

http://www.vidacare.com/ez-io/hospital/patient-care.html

groovy jeff, RN · Oct 2, 2009

I am a brand new nurse and don't know squat.

However in ACLS classes we viewed a movie demonstrating IO and personally I would rather do that than have an IV any day. They claim that they can push an L per hour and that drug absorption is almost as fast. It also appeared less painless and looks like it is well anchored.

Also, the video was amateurish at best, was done by some Residents, and they didn't endorse any products.

Again, I don't know anything and I am just forwarding some information.

APNgonnabe · Oct 5, 2009

I guess I am kind of in the same situation as the OP. Our ER doc responds to the code, and could place a dirty CVL quickly. We use the BIG prehopsital. Used it once, liked it but has some user errors I believe. OP I'll try and attach email w/ our protocol.

CrufflerJJ, BSN, RN, EMT-P · Oct 9, 2009

I am a rapid response nurse & we have had a couple of issues recently with patients we were having difficulty in gaining vascular access either peripheral or through a central line during code situations. We of course gave drugs down the ETT. I am trying to work toward a protocol for the rapid response/code blue & IVT nurses to be allowed to place an I/O in hospital for critical situations such as these.
While I can find a lot of research supporting I/O use including the current ACLS guidelines where it is listed as being preferred over ETT administration, I have not been able to locate any guides for protocols for in hospital placement. I am wondering if there is anyone out there where they do this? Protocols/competencies that you would be willing to share for us to use as a jumping off point? Or ideas where to look?

First, a disclaimer: I am but a mere newbie nurse, an "egg", starting out in the ICU (with 2 whole months experience under my ample belt:D). In my 17 years as a paramedic, though, IO has been very useful in codes. Years & years ago, it was solely used in peds (either arrest or "in extremis"). Over the past 5 years or so, IO has seen increasing EMS use in adult patients (arrest or non-arrest where other access is not available). Waaaaaaaaay back when, the mnemonic for ET delivered drugs was "NAVEL" - narcan, atropine, valium, epi, lidocaine. A bit later, Valium fell out of favor due to questionable absorption via the lung route. With IO, I don't think you have to worry too much about what drugs you can push (MAYBE D50, but I dunno). I'd much rather push them into the bones for delivery into circulation rather than dump them into the lungs, and hope they carry over into circulation & don't muck up the lungs in the process.

We carried the old style push & grind IO needles (Illinois sternal bone marrow needle, or Jamshidi needle) for soft/thin-boned peds. I would NOT recommend these for adults, except maybe for sternal use. You'd take a long while trying to grind your way into an adult's tibia.

Some local EMS units used the Fast-1 sternal IO device, others used the BIG (bone injection gun), while still others use the EZ-IO (sort of like a cordless drill).

Each device seems to have its advantages/disadvantages.

For a review of the BIG - bone injection gun (EMS perspective, including a good review of IO principles), see:

http://emsstaff.buncombecounty.org/inhousetraining/big/big_overview.htm

The BIG is a simple, Israeli military proven, single piece unit with no bells & whistles. Remove the safety clip, push against the tibia, and it fires, driving the needle in. Very compact & simple. There are different models for adults & peds. I believe (but could easily be mistaken) that it is solely meant for use in the tibia, not the sternum. It does result in a big honkin needle sticking out of the tibia, requiring stabilization with gauze or whatnot to prevent an oopsie (shearing/bending/cursing/blaming). A flight EMS/nursing study showed only a 71-73% success rate in obtaining IO access using the BIG. See: http://journals.lww.com/jtrauma/Abstract/2009/06000/Prehospital_Intraosseus_Access_With_the_Bone.39.aspx . Sorry, but in my not so humble opinion, a 73% success rate SUCKS:down:. If I want access, I want access NOW, in all patients. The manufacturer, of course, apparently claims a 96% success rate ( http://www.actnt.com/BIG/Bone_Injection_Gun.htm ).

The Fast-1 sternal IO device promises all sorts of wonderful things, such as delivering meds to the heart 2-3x faster than the lowly tibial IO site (see http://www.fast1sternal.com/how-fast1-works/faqs/#3 ). Some of the medics I spoke to liked it, others had some trouble in gaining IO sternal access with this device in very large (obese/chunky/fluffy) patients. Knowing the patients in our ICU (70 - 800 pounds), I'd want something that would easily work on ALL of them, ruling out the Fast-1. One potential advantage with this device is its low profile after insertion, minimizing the chance of "oopsies" in a stressful arrest situation. The company making the Fast-1 has also recently redesigned the product so it does not require a special removal tool to take out the IO needle.

I like the EZ-IO myself. I have never used it on a real live (or dead:cool:) patient, but have played with the device at a number of conferences and have spoken with one of the folks involved in its development. It is battery powered, sort of like a cordless drill. The device is said to promise a 15 year shelf life, allowing ~1100 IO insertions before needing to replace the lithium battery pack. Access locations include the proximal humerus, distal & proximal tibia, and MAYBE (double check me on this), the sternum. The manufacturer's website ( http://www.vidacare.com/ez-io/hospital/ed--critical-care.html ) claims 10 second access time for ER placements. Based on the videos I've seen, I believe this. No games, no dicking around - clean the site, drill it in, flow the fluids/meds.

Some hopefully useful sites re: the EZ-IO...

- flight nurse related: http://www.flightweb.com/forums/index.php?showtopic=99

- humerus use of EZ-IO: http://acutecareinc.wordpress.com/2009/06/20/humerus-io-using-ez-io-hd-video/

- American Heart study of humerus vs sternum drug delivery during CPR: http://circ.ahajournals.org/cgi/content/meeting_abstract/116/16_MeetingAbstracts/II_933-c (I wish they'd also included tibial drug delivery info, but such is life).

My ICU's "rapid response" bag (we respond to all codes in the hospital) includes an IO access device, but I don't know off the top of my head which manufacturer's unit is included. I'll add it to my "stuff to ask about" list....

As to meeester Groovy Jeff's comment re: lack of pain with IOs, the pain of insertion itself with any of these devices isn't too hateful (based on talking with a person who received a EZ-IO needle & also watching videos of human subject tests on the other devices). The pain comes when fluids are introduced under pressure. I saw a video of a US Army Special Forces medic using a Fast-1 on a "volunteer". He was all smiles:D, even after the device was KRUNCHED into his sternum, until the fluids started to flow. Then, he somehow lost his smile. :eek: Our EMS protocol permitted the IO injection of some Lidocaine prior to running in fluids under pressure. Obviously, in an arrest situation, you're probably not quite so worried about numbing the site.

In a rapid response setting, IO devices allow you to gain access NOW while waiting for the most holy doctor-god (all bow) to show up & place a central line. They are a good thing.

NY_NursingStudent · Jan 17, 2010

CrufflerJJ provided a very good overview of the major devices on the market. My EMS system uses the BIG IO and it works wonderfully. Aside from being quicker than an IV and more efficient than using the ETT it also keeps the provider administering medications away from where the rest of the "action" (i.e. ventilations/compressions/defib) is going on. While it might not be as cramped as in the hospital setiting, I think that they are great devices.

TemperStripe · Jan 17, 2010

We are just getting these in our hospital. The reps demonstrated 2 different devices and they are VERY cool...surprised it's taken this long for hospitals to pick up on these things! Looking forward to hearing about what you come up with.