IO vs External Jugular IV in trauma patients

[DwayneEMTP]

On the topic of c-spine precaution, if the patient has a high cervical fracture then movement could end life. So as Dwayne put it, Life over Limb and by maintaining a neutral alignment on the c-spine, I could very well be preserving life...

Granted, but have you used your portable xray/cat scan to determine that you have such a fracture?

I don't need such things to believe that if I have an obvious femur fracture and a distending belly that the threat of life ending hemorrhage in an entrapped pt may exist, right?

For the sake of argument let's say that you can't get an EJ without lateral movement of the head, surely in theory it sounds like it would be a bitch to do. And let's again assume that you will get 10mL/min flow with the I/O or 60mL/min flow with the EJ (not sure if that's realistic or not on the EJ, but it sounds close.)

With the above described symptoms, would you still choose to protect a hypothetical risk to life as opposed to attempting to mitigate an evident one?

I'm really not arguing for this as I don't know what the most responsible course of action would be. But I do believe that if I had this patient sometime in the next 5 minutes that I would feel the need to manage the fluids first and hope that the EMS Gods would watch out for a spinal fracture.

Also, I've only started two EJs (three attempts) and had no need for a C-collar on any of them, but I don't see the major issue surrounding an EJ and C-collar, assuming that the EJ was placed first and secured with the collar in mind. What am I missing?

And for the record Kate; I think your thoughts are worth way more than two cents...

Dwayne

[FireMedic65]

We were not there to see this patient. Maybe they were in the proper position to place an EJ. Maybe they weren't. Every patient situation is different. If a patient is in an MVC, and their head is lateral, and I see a nice vein, I will do the EJ, and I have. To protect c-spine, and the patient's head is facing laterally, do we not try to gently move it back to the proper position? EVERY patient I have ever seen, that was fully mobilized, was in anatomical position regarding their head. Now, you can't sell me that every patient fell and landed like this, or crashed their car and their body stopped in that position.

[RomeViking09]

I would define an IV as "invasive", an EJ as "moderatly invasive" and an IO as "highly invasive" when it comes to the EMS setting. To continue, why would we be placing an IO into any site if we can obtain an EJ? If a C-Collar, entrapment, etc prevent EJ use then maybe an IO can be placed. Lastly, I would pray that nobody is starting IO's simply for having access. We should only be using such means if we need to administer drugs, fluids, etc.

I agree that an IV is invasive in the the EMS setting but compaired to the use of the EZ- IO, the B.I.G., or even a hand driven IO needle an EJ is much more invasive. The risk to a patient and recovery time from an IO is almost excalty the same as that of a patient who gets an IV (having had a bone marrow sample taken from myself with a hand driven adult IO needle) the only additional risk to the patient from an IO is a fracture in the bone where the IO is placed, the additional risks to a patient getting an EJ are much more serious. I do not see a need for EMS provider who are trained, authorized, and have access to the needed equpment to do an IO to concider an EJ before starting an IO. The only time I would see the need to do an EJ when an IO is an option is after an IO has been estblished and it has failed to provide the needed flow rate for a patient in need of fluids to support their BP.

[ERDoc]

I agree that an IV is invasive in the the EMS setting but compaired to the use of the EZ- IO, the B.I.G., or even a hand driven IO needle an EJ is much more invasive. The risk to a patient and recovery time from an IO is almost excalty the same as that of a patient who gets an IV (having had a bone marrow sample taken from myself with a hand driven adult IO needle) the only additional risk to the patient from an IO is a fracture in the bone where the IO is placed, the additional risks to a patient getting an EJ are much more serious. I do not see a need for EMS provider who are trained, authorized, and have access to the needed equpment to do an IO to concider an EJ before starting an IO. The only time I would see the need to do an EJ when an IO is an option is after an IO has been estblished and it has failed to provide the needed flow rate for a patient in need of fluids to support their BP.

How do you figure an EJ is more invasive than an IO? With an EJ you are putting in in a peripheral, superficial vein, much like when you go in to AC. An IO is being drilled through someones bone, down into their marrow.

[RomeViking09]

How do you figure an EJ is more invasive than an IO? With an EJ you are putting in in a peripheral, superficial vein, much like when you go in to AC. An IO is being drilled through someones bone, down into their marrow.

I am looking at patient recovery, risk vs reward, and stress on the patient. An EJ has far more risk then a peripheral IV (an EJ is not a peripheral line pre many textbooks b/c of it's flow to the heart, many textbooks put EJ just below central lines as far as vascular access and time to action i.e. Transdermal->Oral->Sublingual->SQ->IM->IO->Peripheral IV->External Jugular IV->Central Line->Interacardiac) EJs are more invasive b/c of the risk to the patient and the after care required. If you give someone an IV or IO you can take it out and send them home, EJ you need to monitor them for 12-24 hours after removal b/c of the additional risk of an EJ.

[ERDoc]

I am looking at patient recovery, risk vs reward, and stress on the patient. An EJ has far more risk then a peripheral IV (an EJ is not a peripheral line pre many textbooks b/c of it's flow to the heart, many textbooks put EJ just below central lines as far as vascular access and time to action i.e. Transdermal->Oral->Sublingual->SQ->IM->IO->Peripheral IV->External Jugular IV->Central Line->Interacardiac) EJs are more invasive b/c of the risk to the patient and the after care required. If you give someone an IV or IO you can take it out and send them home, EJ you need to monitor them for 12-24 hours after removal b/c of the additional risk of an EJ.

I think you are confusing IJs and EJs. EJs are nothing more than a peripheral IV. The only difference from an EJ and an AC line are pt comfort. There is no after care required for EJ other than what you have for an AC line. Even with a central line, there is no reason to keep someone for 12-24 hours. I've sent plenty of people home who have had a central line after pulling the line (and that was in the litigation capital of the country, Long Island, New York).

[RomeViking09]

I think you are confusing IJs and EJs. EJs are nothing more than a peripheral IV. The only difference from an EJ and an AC line are pt comfort. There is no after care required for EJ other than what you have for an AC line. Even with a central line, there is no reason to keep someone for 12-24 hours. I've sent plenty of people home who have had a central line after pulling the line (and that was in the litigation capital of the country, Long Island, New York).

I know what I have seen here and if we do an EJ or they do a central Line in the hospital after taking them out they keep the patient for 12-24 hours to be monitored. and I checked the book, I am not confusing IJ and EJ.

[ERDoc]

I know what I have seen here and if we do an EJ or they do a central Line in the hospital after taking them out they keep the patient for 12-24 hours to be monitored. and I checked the book, I am not confusing IJ and EJ.

Wow, that is a little overly aggressive for a peripheral line. You could make the arguement for the central line but even that is not necessary. What is this book you speak of? When you make a statement like that you need to provide a reference. Review your ACLS materials and you will see that the EJ is a peripheral access point. You should be trained in how to do it properly, but to cause a complication you really need to screw it up and probably shouldn't be doing it in the first place. You certainly shouldn't be doing an IO.

[RomeViking09]

Wow, that is a little overly aggressive for a peripheral line. You could make the arguement for the central line but even that is not necessary. What is this book you speak of? When you make a statement like that you need to provide a reference. Review your ACLS materials and you will see that the EJ is a peripheral access point. You should be trained in how to do it properly, but to cause a complication you really need to screw it up and probably shouldn't be doing it in the first place. You certainly shouldn't be doing an IO.

I have always (since learning to do vascular access) been told to go for IO before EJ. Even in paramedic school we did not get much training on EJs other than about 30 minutes of lecture on how to do one and all the things that can go wrong and why we should try an IO first. THe books I looked up in where AMLS and Emergency Care in the Streets (6th Edition).

[scubanurse]

And for the record Kate; I think your thoughts are worth way more than two cents...

Dwayne

Aww thanks! Maybe $0.03? woohoo! I feel special now.

On the topic though, an EJ is a pretty common (at least for me) Peripheral IV site with minimal complications associated with it if done properly and as trained. Maybe it is your training that is the issue here? We learned EJ's in a full class session and had to practice them in clinicals. EJ is usually one of my first sites I look at in a code due to the fact that I'm usually at the head anyways, and an AC access just doesn't cut it when you have 3 big FF's clunking around the patient and can pull the line easily. I prefer EJ any day to an IO, but I also know when the situation is appropriate to do both.

Aaron brings up a good point in that if the patients head is conveniently rolled laterally and I see a honkin EJ sticking up at me...I would consider one attempt only if the patients airway is also cleared and they are breathing adequately.

Rome-- If you think an EJ has more aftercare/risk than an IO I suggest you go try having one of each. An IO is drilled in to the bone and the people I have talked to who have seen the site 12-24 hours after removal, say the patient had site discomfort whereas an EJ feels like none other than a peripheral IV...

Have a fantastic week y'all and be safe.

Kate