Intraosseous

I ran in Ohio as an EMT-B and we're not allowed to do IOs but I saw one once during a cardiac arrest. They blew their first attempt at an IV and an overeager (IMO) paramedic started an IO. Only it turned out that the IO was unusable and they wound up getting two IVs started. Judge from that what you will.

But I know our Intermediates and Paramedics were really excited when we got "the big guns," as they called them, on the medics.

Good luck with both of your endeavors!

I have been an ER nurse for 11 years. I can not begin to count how many times the IO has come to the rescue. Our EMS uses the IO frequently in codes especially, but also diabetic emergencies.

Our hospital uses the EZ IO which is awesome.:redpinkhe It is amazingly easy to insert, you just drill it in. We have both the adult and peds set up. Our physicians use it often as an alternative to central lines, especially in pediatric emergencies. The only problems we have encountered was a few of the set ups had leaks in the plastic phlange due to cracks in the plastic. I am not sure if they were faulty or if the physician may have drilled them too much resulting in cracks in the plastic.

Another problem I have observed is if you do not hold the drill at the proper angle the skin can begin to twist with the drill, which looks extremely painful. I have only seen it used once on a conscious patient, and they said it was not very painful. In the in-service video made by the company, there are doctors and nurses who volunteer to have one inserted on them. One guy said "ouch" otherwise no one really complained.

I have used the old IO systems and the EZ IO and the EZ IO is definitely better. It rocks.

Hope this helps.

Bit of an underachiever there aren't you Sal B ??? Kidding

Guess there really is no limit to the amount of torture that we will go through to be great at what we do - nursing school and then EMT class - rock on there Sal!!!

IO access is IMHO is not used enough. I think that your instructor is spot on. I mean that willy-nilly use is bad, but deliberate and meaningful clinical practice is what sets the best apart - resolve to be the best at whatever you do!

I had placed a handful of manual placement of IO's (several pedi codes and one adult - kinda always squeamed me with that crunch through the bone). Did okay - but...

Did a couple of Fast-1 sternal IO's - did not like them too much either - I felt like they were difficult to place, with limited flow.

Recently did my first humerus EZ IO (the one with the drill) in a 30ish trauma patient that was A&O x 3, but with crapped out veins from recreational drug use - in hindsight I was a little hesitant due to the fact that the patient was "with it" (had used it before as tib placement in the obtunded). Well, I am a believer now. I will not hesitate in the future. Reasonable attempts at peripheral access and then I will go to the EZ IO - no delay. My clinical practice guidelines support the practice of no delay - regardless of LOC.

I think that technique is everything.

Site prep. Site selection.

Be certain to get all the supplies ready in advance. (Good site prep, Prime the extension set, Sterile dressing, 2 rolls gauze and tape for stabilization, 2% lido push for post insertion pain control and several flushes and pressure bag for infusion set, ID'ed arm band to detail placement) Should not take more than 30 seconds to get it ready (I have it all bagged with the drill).

Be deliberate and drill with purpose. Too much force could crack the plastic "hub" and may cause leaking. I did not have that problem.

I flushed the line aggressively before I secured it (meaning I held on to the site) to ensure that I had no extravasion (held my fingers on either side of the access - no edema felt - important) and gave a healthy dose of fentanyl too. After aggressive flushing and ensuring no extravasion I did aspirate excellent blood return. Stabilized the site externally and then we were good to go! I think that to aspirate first just invites marrow obstruction (before flushing) and may render the site useless. I was a bit shocked at just how well it flowed and the speed the medication worked - comparable to central access IMHO.

Anyway, I hope that this helps -

I do not have any experience with the Vitacare, but you cannot go wrong with the EZ IO (the drill method). You can use it pedi 3kg + and it gives you multiple sites in the adult. I have it on good authority that it is not that painful on insertion (check youTube - yep, there is video) - removal will be a different story. We do keep manual IO's for placement when the drill is not indicated. I also can do a UVC in the neo - so I cannot think of a situation that manual placement would be necessary. Plus central access remains an option - but I prefer the EZ IO!!

I am going to a bit more aggressive with the EZ IO use in the future. We are always working to improve delivery of optimal care and our scene times - sure beats central access in most patients.

Best of luck in school and beyond - Where are you practicing at???

If I can help further - just let me know.

Practice SAFE!

Bit of an underachiever there aren't you Sal B ??? Kidding

Guess there really is no limit to the amount of torture that we will go through to be great at what we do - nursing school and then EMT class - rock on there Sal!!!

IO access is IMHO is not used enough. I think that your instructor is spot on. I mean that willy-nilly use is bad, but deliberate and meaningful clinical practice is what sets the best apart - resolve to be the best at whatever you do!

I had placed a handful of manual placement of IO's (several pedi codes and one adult - kinda always squeamed me with that crunch through the bone). Did okay - but...

Did a couple of Fast-1 sternal IO's - did not like them too much either - I felt like they were difficult to place, with limited flow.

Recently did my first humerus EZ IO (the one with the drill) in a 30ish trauma patient that was A&O x 3, but with crapped out veins from recreational drug use - in hindsight I was a little hesitant due to the fact that the patient was "with it" (had used it before as tib placement in the obtunded). Well, I am a believer now. I will not hesitate in the future. Reasonable attempts at peripheral access and then I will go to the EZ IO - no delay. My clinical practice guidelines support the practice of no delay - regardless of LOC.

I think that technique is everything.

Site prep. Site selection.

Be certain to get all the supplies ready in advance. (Good site prep, Prime the extension set, Sterile dressing, 2 rolls gauze and tape for stabilization, 2% lido push for post insertion pain control and several flushes and pressure bag for infusion set, ID'ed arm band to detail placement) Should not take more than 30 seconds to get it ready (I have it all bagged with the drill).

Be deliberate and drill with purpose. Too much force could crack the plastic "hub" and may cause leaking. I did not have that problem.

I flushed the line aggressively before I secured it (meaning I held on to the site) to ensure that I had no extravasion (held my fingers on either side of the access - no edema felt - important) and gave a healthy dose of fentanyl too. After aggressive flushing and ensuring no extravasion I did aspirate excellent blood return. Stabilized the site externally and then we were good to go! I think that to aspirate first just invites marrow obstruction (before flushing) and may render the site useless. I was a bit shocked at just how well it flowed and the speed the medication worked - comparable to central access IMHO.

Anyway, I hope that this helps -

I do not have any experience with the Vitacare, but you cannot go wrong with the EZ IO (the drill method). You can use it pedi 3kg + and it gives you multiple sites in the adult. I have it on good authority that it is not that painful on insertion (check youTube - yep, there is video) - removal will be a different story. We do keep manual IO's for placement when the drill is not indicated. I also can do a UVC in the neo - so I cannot think of a situation that manual placement would be necessary. Plus central access remains an option - but I prefer the EZ IO!!

I am going to a bit more aggressive with the EZ IO use in the future. We are always working to improve delivery of optimal care and our scene times - sure beats central access in most patients.

Best of luck in school and beyond - Where are you practicing at???

If I can help further - just let me know.

Practice SAFE!

This is an AWESOME reply and very positive...I worked a peds code not too long ago and since an event such as this is rare I asked the RN about inserting an IO...she looked at me like I was nuts and walked away.

Ok...so we agree then this is the way to go pre-hospital? I have read protocols which state two failed attempts at peripheral access or 90 seconds indicate IO.

I read something about using Lido -- your quote "2% lido push for post insertion" -- EZ IO calls for 10cc sterile for post insertion -- will the lido inhibit in any way...can't recall exactly what I read.

I practice in Georgia...I currently work in the ICU PRN and hope to find myself with Emory Flight once I graduate.

Thanks again for the input

I have been an ER nurse for 11 years. I can not begin to count how many times the IO has come to the rescue. Our EMS uses the IO frequently in codes especially, but also diabetic emergencies.

Our hospital uses the EZ IO which is awesome.:redpinkhe It is amazingly easy to insert, you just drill it in. We have both the adult and peds set up. Our physicians use it often as an alternative to central lines, especially in pediatric emergencies. The only problems we have encountered was a few of the set ups had leaks in the plastic phlange due to cracks in the plastic. I am not sure if they were faulty or if the physician may have drilled them too much resulting in cracks in the plastic.

Another problem I have observed is if you do not hold the drill at the proper angle the skin can begin to twist with the drill, which looks extremely painful. I have only seen it used once on a conscious patient, and they said it was not very painful. In the in-service video made by the company, there are doctors and nurses who volunteer to have one inserted on them. One guy said "ouch" otherwise no one really complained.

I have used the old IO systems and the EZ IO and the EZ IO is definitely better. It rocks.

Hope this helps.

Thank you for the reply...

Are you aware of any complications such as infection? I understand that infection comes with the territory but I am thinking that we have a hole in the bone...perfect door for somthing "kill-u-aureus". :nuke:

I have posted on this before. Intra Osseous..as an emergency procedure, as a last stand, ok, go for it. Otherwise..It HURTS like the most pain you could ever feel in your life!!!!!! I have had it, don't recommend it, as I said, other than no other acess emergency stuff!

OOOOWWWWWWWWW!...So much worse than delivering 3x almost nine pounders on my own!!!! In fact, I'd rather deliver a 12 pounder than have anything taken through an IO acess again!!!!!!!

JMHO...btw!

HEY... I made a mistake ---> VIDACARE not viTa

Some links --

http://www.vidacare.com/

http://www.vidacare.com/Training_&_Education/EZ-IO®_StarCast_(Online_Training)/index_12_286.html

You have to visit the training site!

I need to try this!

I have posted on this before. Intra Osseous..as an emergency procedure, as a last stand, ok, go for it. Otherwise..It HURTS like the most pain you could ever feel in your life!!!!!! I have had it, don't recommend it, as I said, other than no other acess emergency stuff!

OOOOWWWWWWWWW!...So much worse than delivering 3x almost nine pounders on my own!!!! In fact, I'd rather deliver a 12 pounder than have anything taken through an IO acess again!!!!!!!

JMHO...btw!

12 pounder? Ouch! My anatomical configuration does not allow for child birth :nuke: -- but I can feel your pain.

What site was your IO, what was your level of consciousness and WHY was IO chosen for you?

I ran in Ohio as an EMT-B and we're not allowed to do IOs but I saw one once during a cardiac arrest. They blew their first attempt at an IV and an overeager (IMO) paramedic started an IO. Only it turned out that the IO was unusable and they wound up getting two IVs started. Judge from that what you will.

But I know our Intermediates and Paramedics were really excited when we got "the big guns," as they called them, on the medics.

Good luck with both of your endeavors!

Thanks for the reply. Curious....do you know why the IO site was not usable?

As if nursing school was not enough...

I am taking an EMT - Intermediate class...

We are knee deep in IV therapy and the instructor is pushing Intraosseous...

I have never performed an IO and I doubt I will ever see one in clinical so my question for the forum is...

What are your thoughts on IO in a pre-hospital setting?

Does anyone have any experiences pertaining to IO they wish to share?

Is anyone familiar with the EZ-10 or Vitacare?

Thanks in advance?

IO access is a good tool to have in the field. I think it has a place in the hospital as well; however, it is a great option when rapid IV access is required and conventional IV access is not an option. It is an invasive procedure and adequate education is required prior to letting ALS providers use the technique. In addition, a strong QA/QI program should be established and people should be monitored to ensure that IO access is used properly.

My company uses both the FAST and EZ IO for adult patients.

I have personally used the FAST two times. The last time I placed it, my partner and I intercepted an ambulance. The patient had a GSW to the head. The patient would only respond to a sternal rub with mumbling and was breathing slow and irregular. The EMS crew was unable to establish IV access (tried one in each AC) and had to perform BVM ventilations at times.

My partner and I decided the patient needed definitive aiway protection and opted to RSI. Because EMS tried both arms, the legs and EJ placement were options; however, we decided to place the FAST for rapid IV access. I used the FAST while he pulled out the intubation kit and our rescue airway. In less than 30 seconds I had IV access. The patient was quickly RSI'd without incident and flown to the closest trauma center about 50 minutes away.

Here are some really good articles that answer most of the questions you have including use of a pain scale related to GCS score. Pretty interesting.

http://www.docseducation.com/docs_ezio/red_disk_files/Clinical%20Trial%20Result.pdf

http://www.vidacare.com/reports/Military%20040007.pdf

This article discusses some of the complications related to IO, but does not give any real stats in regards to infection rates.

http://www.emedicine.com/ped/topic2557.htm

Thanks for the reply. Curious....do you know why the IO site was not usable?

In the hubbub I never got specifics, but I know they couldn't get the fluids to run so they discontinued it and just used the IVs.