EZ IO placement

[jwraider]

I thought I'd add our county protocol for this.

First it states an IO is for an emergency (a real one!) with a GCS of 8 or under.

For concius PTs or a PT who regains concioussness admin Lidocaine 2% 0.5mg/kg max 50mg slowly. After 30-60 seconds flush with NS.

It explains for the PT regains consciousness and complains of severe pain at the IV site to stop the infusion and admin lidocaine just like above. (Notice it says stop the infusion inferring that is what is causing the pain).

Edited May 3, 2009 by jwraider

[DwayneEMTP]

I'm curious as to the mechanism of the interosseous pain that would need to be mediated?

Since seeing this question a few years back here at the City I've made it a point to ask anyone and everyone that has ever had need to use an IO device this question and all have said that there was no significant pain with infusion. The doctors, Perhaps a half dozen, whom all claim to have started "numerous" IOs claim that there are none of the necessary receptors in the IO space to cause the stated pain upon infusion.

Anyway, I've seen here where people in this thread have claimed that this is "the worst possible pain", but I can't find the mechanism, with only a small amount of Googling, and the doctors that I have talked to claim that it CAN'T exist, so what's the deal??

I'm not even sure what the receptors would be? Mechanical, thermal, Chemo, Barro, stretch? (Yeah, I know, I'm a few years post A&P so I'm probably mixing and missing them)

Anyway, to those that claim that a lido bolus is necessary prior to running fluids to mediate pain I'd be curious to hear you explanation.

Thanks all.

Dwayne

[rumedic]

I'm curious as to the mechanism of the interosseous pain that would need to be mediated?

Since seeing this question a few years back here at the City I've made it a point to ask anyone and everyone that has ever had need to use an IO device this question and all have said that there was no significant pain with infusion. The doctors, Perhaps a half dozen, whom all claim to have started "numerous" IOs claim that there are none of the necessary receptors in the IO space to cause the stated pain upon infusion.

Anyway, I've seen here where people in this thread have claimed that this is "the worst possible pain", but I can't find the mechanism, with only a small amount of Googling, and the doctors that I have talked to claim that it CAN'T exist, so what's the deal??

I'm not even sure what the receptors would be? Mechanical, thermal, Chemo, Barro, stretch? (Yeah, I know, I'm a few years post A&P so I'm probably mixing and missing them)

Anyway, to those that claim that a lido bolus is necessary prior to running fluids to mediate pain I'd be curious to hear you explanation.

Thanks all.

Dwayne

The need for the flush is to make a larger area in the marrow to absorb the fluid you have running. the pain is from the pressure of pushing the marrow away from the tip of the needle that is why you start with lid if possibale then it numbs the area you are moving. the more the marrow expands the greater the surface are to absorb the fluid you are giving and the better the iv will run.

[Kaisu]

I'm curious as to the mechanism of the interosseous pain that would need to be mediated?

Since seeing this question a few years back here at the City I've made it a point to ask anyone and everyone that has ever had need to use an IO device this question and all have said that there was no significant pain with infusion. The doctors, Perhaps a half dozen, whom all claim to have started "numerous" IOs claim that there are none of the necessary receptors in the IO space to cause the stated pain upon infusion.

Anyway, I've seen here where people in this thread have claimed that this is "the worst possible pain", but I can't find the mechanism, with only a small amount of Googling, and the doctors that I have talked to claim that it CAN'T exist, so what's the deal??

I'm not even sure what the receptors would be? Mechanical, thermal, Chemo, Barro, stretch? (Yeah, I know, I'm a few years post A&P so I'm probably mixing and missing them)

Anyway, to those that claim that a lido bolus is necessary prior to running fluids to mediate pain I'd be curious to hear you explanation.

Thanks all.

Dwayne

The sensory receptors within the human body are sensitive to tissue damaging or stimuli that are prevalent in skin, muscle, joint, bone and other connective tissues. Those nociceptors (sensory receptors) are sensitive to response to mechanical, thermal, and chemical cutaneous stimuli. It is believed that nociceptor sensitization is a physiologic mechanism of persistent pain. Once nociceptors activated locally, it transduces chemical, mechanical, or thermal stimuli into afferent impulses that enter the nervous system to the brain for pain perception. Particularly, A-δ mechanoreceptors and C-nociceptors appear to be localized to connective tissue between muscle fibers and in blood vessel walls or tendons, and in the joint capsule and periosteum.

Particularly, numerous studies have shown that the periosteum, which is comprised of fibrous connective tissue sheath that covers the external surface of all bones, is densely innervated by both sensory and sympathetic fibers. Nerves are distributed to the Periosteum and accompany the nutrient arteries into the interior of the bone. Fine nerve endings are found in bone marrow, periosteum, cortex, and associated muscles and ligaments. The prevailing opinion is that bone pain arises predominantly from the densely innervated periosteum, where is the area of interest for ablating local pain receptors utilizing ultrasound to reduce bone pain.

[HERBIE1]

Good topic.

We are just starting with this protocol now. (Yeah, I know-our system isn't exactly on the cutting edge) I find it interesting that prior to roll out of the EZ IO, we saw a refresher DVD from the manufacturer that indicated the Lidocaine flush, but our protocols and initial training do NOT call for it- just the 10cc's of saline to create a space for the infusion. Maybe at some point we will adopt the Lidocaine flush, but we'll see.

I've done a couple IO's the old fashioned way- always in peds arrests, and it was a brutal and barbaric process- manual insertion, so I'm happy for this new device. Our protocols are for patients in extremis- no specific glasgow-like impending arrest, unstable traumas, or anytime IV access is not only indicated but NEEDED, etc.

I do know that the pressure bag/BP cuff is mandatory- gravity flow will NOT work-there is simply too much resistance.

I'm not second guessing anyone here either(Monday morning QB's are a pain) but unless the patient is status epilepticus and decreasing O2 sats, if I needed to push Valium, I would probably go the IM route if IV access is not possible. Yes, it takes a bit longer to metabolize, but will still work, and as long as the patient is not critical, the delay won't be much of an issue.

All you IO experts- keep those comments coming- I'm sucking all this info up like a sponge.

[hertzvanrental]

Sorry to hijack. A UK perpesective. My service is the only ambo service in the UK to use the EZ-IO (there are a few HEMS dotted around that also use it) most others use FAST, BIG and traditional methods (although paeds only for those that use the latter). We've been using it for a few years now.

We can use it on anyone, adult/paeds, cons or unco. We use lido 20-40mg adults and 0.5mg/kg on paeds. We can push every IV drug/fluid through it (except heparin and tenectaplase) if we need to.

I've used it several times and found it to be an excellent addition to our arsenal of skills. A lot of the time it is used in arrest situations but personally I have also used it in severe hypotension where the patient has been shut down. Also in paeds burns, 2 yr old burns to head neck, back & chest, unable to get IV so popped in an IO, lido then morphine, worked a treat. The child was too busy screaming with the burn pain to think about the IO. We also had a young patient who had a femoral haematoma that popped and was bleeding out, she had 3 IO's in! Great bit of kit!

Having said that, if I can get an IV I'll get an IV.

As for the valium question, do you guys not use rectal diazepam? Unless the patient was status then I'd probably have to resort to the brown route (LOL). There are also veins in the feet or ankles that we use on seizure patients.

[fireflymedic]

Thanks for the UK perspective there Hertz ! Rectal is an option, however due to adult pt size it typically is not as viable an option though it has been used for peds. In my area along with several others surrounding the US there is a trial of an auto injector of Versed (I know IM is already an option, but they are trying to put the science behind it saying it is just as quick as attempting to get an IV established). Here we have several varieties of tools in our tool box depending upon the patient. Your frequent seizure patients may not even have veins due to the repeated caustic drugs pumped into them which have destroyed them (ie dilantin, phenobarb, etc). Here's our potential line up for choices

1. Ativan, Valium, and Versed are all in the aresenal though truthfully valium is probably the least used out of the bunch. Versed tends to be favored, but I'd say depending on the area it's a mix between it and Ativan. Both are able to be given any route and are long acting with short onset.

2. IO, MAD, or traditional IV. If all else fails or for pedi - rectal. I would not hesitate to go to an IO in a seizing patient I could not get a line on within a reasonable amount of time, and for whatever reason MAD was not an option. That's my personal though.

As far as conscious patients - burn patients I feel could benefit probably the greatest from it. As far as others, there are instances but the majority of the time you can find something. If conscious, lido please - don't torture them. The periosteum is extremely sensitive and rich in nerve endings - this is actually what they numb for bone marrow aspirations in addition to the skin. You have heard how painful those are, imagine that for a conscious patient and then pushing medications through into a space within the bone. I have never experienced it, but I can only imagine it would not be a pleasant feeling. Be kind to your patients - a little lido will do alot of good !

[Just Plain Ruff]

Ok, now that we've discussed the benefits and pitfalls of the IO let me ask this

The manufacturer calls for in all it's literature a flush of lidocaine to minimize pain. I would say that most of us will never get an IO so we won't know the pain involved but what happens in your protocol when you do not follow the manufacturers directions when it specifically says to flush with lidocaine?

Are we (those who approve the protocols) committing negligence or injury when we don't follow the manufacturers recommendations?

What kind of liability are we facing when we go against what the manufacturer says.

Discuss!!!!!!!!!!!!

[fireflymedic]

Ok, now that we've discussed the benefits and pitfalls of the IO let me ask this

The manufacturer calls for in all it's literature a flush of lidocaine to minimize pain. I would say that most of us will never get an IO so we won't know the pain involved but what happens in your protocol when you do not follow the manufacturers directions when it specifically says to flush with lidocaine?

Are we (those who approve the protocols) committing negligence or injury when we don't follow the manufacturers recommendations?

What kind of liability are we facing when we go against what the manufacturer says.

Discuss!!!!!!!!!!!!

Ruff - good point there. The way I look at it - it is a deviation from accepted practice (being as the accepted and recommended practice is to flush with lidocaine). As I recall that is one of the things which must be proved to gain damages from malpractice - so potentially I think we could be held to that standard. I wouldn't be suprised to see it happen, especially in the day and age of everyone is sue happy and all is available on the internet. When it comes to being put on a stand in court and being told "the manufacturer says to flush with lidocaine, this was done after extensive research, why did you not feel the need to do so?" I think it would call into question to be a critical thinking medic as opposed to a cookbook medic. If you are capable I would say after reading this, I would have a discussion with your training officer, medical director and see if there is an ability to change the protocol based on what has been stated along with the recommendations. As mentioned many times before, we should not blindly follow and I think more need to actively participate in writing and reviewing of protocols rather than saying, this is what our service does, so this is what we do. Don't be afraid to question or challenge things - do your research and question it and get discussion going within your services independently ! I consider that as much of my job as picking up patients from the scene and treating them because this ultimately affects how I will treat them. Any other thoughts?

[rpm911]

See FAQ...

http://www.vidacare.com/ez-io/clinical-res...enter/faqs.html