EZ IO placement

[20EMSyears]

I am a certified paramedic in two different counties in one we flush with lidocaine(40mg) and in the other one we use the prefilled flush that comes with the EZIO pack. We only use the IO in pt that are "critical" in other words most of the people we will use it on will have no recollection of the IO since they are either unconcious/dead/near death. So I dont think the IO will be much of an issue for those patients.

Also instead of going to the IO in this situation...We will probably do INTRANASAL VERSED first , is this an aproved protocol where you work, if not maybe you guys can look into it. It will be give you one more tool in your tool box should (and it will) this situation/call arise again.

[AnthonyM83]

I don't think there's been any mention of anesthesia for IO's in either in my class by any instructor or main lecturer or mention in the books. Maybe it's a newer thing, since many places started out only using them for cardiac arrests, thus the issue wouldn't come up...

[tskstorm]

I'm with Anthony here, no one has mentioned the use of Lido for an IO and it is certainly not in protocol, I wonder If one could call medical control for an order....

[paramedicmike]

Or is it more that your medical command docs don't expect it to be used in anything but a cardiac arrest situation?

Which would be a shame...

-be safe

[Just Plain Ruff]

20-40mg 2% (20mg/ml) lido on initial flush is what I have been taught.

SpO2 100% on a seizuring patient...... Sounds like one of those situations where you must look at the patient and not the monitor... Not that I am judging... just pointing out something to think about, it is not very often seizuring pts have adequate resps.... if any at all.

I have heard that bone pain is the worst pain of all (heard).

Sounds like a good call, and a job well done Ruff.

Yeah 100% go figure, it turns out that earlier in the day the patient got an EJ iv. It also turns out that we discussed his case with his psych doc and the psych doc says that he is not a true seizure patient but pseudo seizure patient and he is a great faker at being unconscious.

I had a feeling he was faking but the IO was not placed based on that feeling though. I could have gone with a EJ but hey, the IO was handy.

I pinched the back of his arm with all my might, to the point of hurting myself, and he didn't flinch.

His resps were about 16-20

[fireflymedic]

Man, he deserves an award for that performance. Everyone I have ever placed an IO on has given some reaction to pain even with premed with lido - you said his was short lived - WOW - talk about a serious pain tolerance. I've not heard of premedication with versed for IO's - that's a new one on me, but I think any service which does not permit some form of pain management for a quite painful procedure is behind the times and needs to have a discussion with the med director. I've seen a few that were fairly "out" still give a reaction to pain. The pain not from insertion of it, but the continued infusion. Bone pain is incredibly painful and I pity anyone, faking or not that receives an IO.

As far as the issue of increased risk for infection, heck yeah there is one. You just put a hole in the bone ! Here it usually warrants an overnight stay in the ER or CDU for short term observation and prophylatic dose of antibiotics. I understand that isn't standard everywhere, but how the docs roll here.

For the fact he's a pseudoseizure patient - there's really two classifications of these guys. One of which isn't faking - the seizures are actually happening to them, they are just a conversion disorder and NOT under the patient's conscious control. They can really be unconscious to the point they can't protect their own airway, even have what is similar to a post ictal period. These are the concerning patients - they aren't seeking drugs, they are scared about what's happening to them and should be handled with gentleness and respect, and are usually followed jointly by a neuro and a psych (as many times after these patients have received a video EEG they are found to have frontal lobe seizures which are more difficult to detect and require special electrode placement, etc and difficult to find on routine EEG's). The second group is the flat out fakers aka factitious disorder or malingers. They have something to gain from the faking either the sick role (factitious disorder) or financial like workman's comp, disability, etc (malingers). They are the ones that may also be seeking drugs and are worrisome from the point they may attempt to sue for malpractice saying you didn't treat them appropriately by giving medications. They can be all out trouble if one is not careful.

For both variations of patients, if in question, treat as you would a normal seizure patient (you did fine Ruff), but we tend to get the med director involved and if possible the neuro as many a time we have received orders not to further medicate if meds have been given (we have one patient we've transferred multiple times for this very issue and that's the general rule). Another option you have is to give a saline flush - no harm done there to patient and see if they stop seizing. If so, don't follow up with meds. If they don't, you can give meds. There is no harm done as you are still treating the symptoms if unresolved, and if so, it would have terminated by time meds were given, so no real time is lost and avoids giving meds unneccesarily. At any rate, always protect them from themselves and watch those sats. There are some patients, especially with shorter seizures that will maintain reasonable sats, so don't stress out and most improve quickly shortly after the seizure ends. Also - keep on the watch for seizures other than generalized ones - they don't present the same way, but are seizures and can cause problems nonetheless.

Stay safe out there and treat those patients well !

[Just Plain Ruff]

I treat every patient the same, faking or not. If they warrant an intervention they get it. If they don't they don't get it.

This guy is very very very very very very very very very well known to us in our ER and his LOC was concerning so he got treated as any seizure patient would.

I gotto go on a transfer now so I'll be back.

[tskstorm]

Or is it more that your medical command docs don't expect it to be used in anything but a cardiac arrest situation?

Which would be a shame...

-be safe

When originally taught the IO skill, we were taught the many uses, however after thumbing through my protocol book, it does seem that the current case is as you stated its pretty much only used in arrest situations, however I'm certain we could get an order for such if the situation warranted it.

[backinboston]

Ive been using the IO pre hospital for about three years now, with great success when it is needed

First, your checking your patency when you push your prefilled NS flush, and it should go in pritty easy

Second, if your gona hang a bag , and i reccomend it, you need to put a compression bag (if you dont have one pump up a BP cuff) around the NS bag.

Third, why would you remove the IO? Keep it in and leave it set up for the hospital to use when you get there. They are great tools and if your using the IO, you should not be able to obtain IV access.

Finally, the patient isnt really gona feel pain from the drill. Its when you go to push anything through it that they will be in pain. Its becuase the receptors in this area of the bone respond to pressure not pain stimulous. On an adult you can take your prefilled Lido (that you use in codes) and push 20-40mg. This will relieve the pain caused by pushing fluids into the marrow.

I have never had problems with the IO except on large patients that have a lot of tissue (FAT) between the skin and bone. Use at your own caution in these. But like I said before if im going to the IO, it means i cant get an IV. Usually on the fat ones Ill just do an EJ. However, these are great tools and give you a patent IV in less than 30 seconds.

-boston

[jwraider]

I haven't had to do an IO on someone yet on someone who would feel anything. I know some counties have lido in their protocol to flush with as that is when the most pain is felt. My guess would be the pain is felt as long as you are pushing anything through the IO.

I've used the standard size on a larger patient and the fat tissue just seemed to compress under the plastic and the catheter ended up in the right place.

I wasn't on the call of course but do you guys have protocols for Valium to go other routes besides IO/IV ? Seems like this guy would have had good perfusion if he was faking an IM injection of Valium or Versed would have worked. Some systems now have intranasal versed which is great for seizures in my opinion.

I'm not trying to second guess you as much as I'm pointing out painful IOs can be avoided.

I think it would be interesting to discuss situations where an IO is needed for a concious PT and how we would handle it.