IO vs. IV in a drug overdose situation

[2Rude4MyOwnGood]

Recently responded to a 21yr old female who had overdosed on heroin. She was unresponsive but had a pulse when we arrived. In the back of the unit she became responsive to pain. Rather than start an IV for the Narcan/fluids, the medic dropped an IO in her tibia.

Just curious what the benefit to doing this was. Save time? Does the Narcan absorb more efficiently through the bone? I didnt see any track marks on her arms to indicate that those veins were no good but i didnt get too close of a look.

[Timmy]

In my very limited experience and exposure to such events I’m probably not the best person to give feedback…

I think IO is gaining in popularity and seems to be seeping into more and more practitioners scope of practise, fantastic tool when things are going down hill quiet rapidly.

I think we need to paint a better clinical picture here, was gaining a peripheral or central line not available at the time? Poly pharmacy overdoses can sometimes dehydrate quiet quickly making peripheral cannulation quiet challenging. Every case is different and I wasn’t on scene but if the patient is ?maintaining a patent airway or even had adequate perfusion with ventilation and had an output, I think I’d be more incline to go with an IVC or CVC and use IO as a fallback. I’ve only witnessed IO used as a last restore in a resuscitation case were peripheral access was challenging secondary to sever dehydration, I’m also aware IO may be indicated and the access of choice for paediatrics patients in some strife.

IO is quiet out of my depth and I really haven’t researched it much but I’m guessing the onset and peak of medication though an IO may be slightly faster than a medication administered through an IVC due to direct diffusion into the medullary canal and coming into contact with the red blood cells, of course Naloxone is hepatically metabolised so it may just be faster to give the medication into the venous supply.

[JTpaintball70]

On this patient I most likely woldn't have done an IO. There's too many ways to give Narcan that would work. You could give IN or IM and get good results. How was her respiratory pattern? If it was adequate I would have just left her alone and only given narcan to stop respiratory depression, not bring her completely awake.

[MEDICMAN1]

In this situation I would not have place an IO in this pt.

It all depends on protocol but this type of situation you would look for an IV or give the Narcan IN or IM if need be. The IO is a great tool in the right situation. Usually, its in an arrest or in a unresponsive pt with no IV access and your fighting time. The medications that get pushed through the IO do get into the central circulation faster( great video on youtube showing it) but in this case with the narcan and heroin I would push it slow or your going to have a pissed off vomiting pt on your hands.

The IO is great and easy depending on which device your service uses and I think that alot of the ALS providers are becoming lazy and taking the easy route on pt.'s who don't need it because of the simplicity of it. It all comes down to doing whats right for your pt. and following what your protocols allow.

Thats just my opinion on the call.

Everyone stay safe out there.

[Just Plain Ruff]

I think this is open to debate IV versus IO but in my opinion, one of the only reasons why I'll drop an IO is if I cannot get a peripheral be it AC, hand, EJ or what not.

IO's are perfectly acceptable but they are pretty brutal and most ER's are not used to seeing IO's in adults so they are not widely used where I work.

I have put in maybe 3 or 4 since the beginning of the year.

If the medic didn't search for a peripheral site (and I'm not saying that he did or did not) then I think the IO was overboard.

But if he did search and didn't find a peripheral, and we all know that Heroin addicts usually have Zero veins, then the IO was appropriate.

Now the dark side of me wants to think that the medic did this just because he could and because he might have wanted to teach that girl a lesson. If that's the case then shame on him but I do know several medics who would do just that so this thought process of mine is not based on mere conjecture.

I think we definately need more information before we go and truly pass judgement on this medic.

[DwayneEMTP]

I think this is open to debate IV versus IO but in my opinion, one of the only reasons why I'll drop an IO is if I cannot get a peripheral be it AC, hand, EJ or what not.

IO's are perfectly acceptable but they are pretty brutal and most ER's are not used to seeing IO's in adults so they are not widely used where I work.

I have put in maybe 3 or 4 since the beginning of the year.

If the medic didn't search for a peripheral site (and I'm not saying that he did or did not) then I think the IO was overboard.

But if he did search and didn't find a peripheral, and we all know that Heroin addicts usually have Zero veins, then the IO was appropriate.

Now the dark side of me wants to think that the medic did this just because he could and because he might have wanted to teach that girl a lesson. If that's the case then shame on him but I do know several medics who would do just that so this thought process of mine is not based on mere conjecture.

I think we definately need more information before we go and truly pass judgement on this medic.

Man, what a great thread, I've got not useful to add except to say that with the exception of IOs being brutal (I don't think they're fun, but not chest tubes either) I agree with Ruff's post down to the word. If good assessment skills were used and a rational decision made, awesome. If it was done 'because I can' or as a punishment? I hope the shithead is getting struck by lightening as we speak.

One thing I would like to add though is what a joy it is to see a thread where every single person gave an opinion and then explained their opinion! (well, except me I guess, who piggybacked Ruffs opinion) There's not a single "screw it, take her to the hospital if she's breathing" or some like bullshit in the thread. It's the best of what we do here, and it sets an amazing example for those that are younger or newer here.

Thanks to you all for the education that you've given and continue to give me at the City.

Dwayne

[HERBIE1]

The only question I have to this is "What was her respiratory rate?"

"Unresponsive" does not say much. What was her Glasgow? What were her vitals? What about her pulse ox? If her O2 sats were lousy, breathing at 2/minute, and she was cyanotic, then I would have no problem with an IO- perfectly appropriate.

As for heroin users having poor veins- I disagree. Of the hundreds of OD's I have seen, I would say about 80+% or more who use this stuff actually snort it- only the hard core users shoot it up, thus a person won't necessarily have lousy peripheral veins. IM is a perfectly acceptable route for someone who has stable vitals and O2 sats. Yes, it takes a bit longer to work, but in an otherwise stable patient, there is no urgent need to drop an IO.

The IO route is for a person who is in extremis, not someone who is simply just "unresponsive".

I also won't bash the provider who did the IO here without knowing more details about the patient.

[Just Plain Ruff]

I agree Herbie. I won't bash him either and I hope that's not how my original post came off.

But I also agree that IO's are for the patient that is eitehr crashing or going there.

A unresponsive person would not warrant a IO without some additional criteria being met at least to me that is.

The generic response would be 3 iv attempts and then IO is a rule to stick to most of the time.

If I have a critical patient and I cannot get an IV in the AC or the EJ the first time then IO is the way to go.

I prefer the EZ IO drill. You can drop an IO with that device in less than 10 seconds from start of the drill to hooking up the line.

one thing to remember with those is to make sure you choose the correct needle size. Nothing worse than choosing a long needle and drilling all the way into the other side of the bone. Fluid definately does not flow then and it does cause tremendous pain in trying to flush the fluid into the bone and not the marrow space. I speak from experience here on this. Trust me.

As long as you get the right size needle then you are golden most of the time.

Taking out the IO needle I found causes more pain than putting it in if you use the drill or it may just be that when I've taken the IO out the patient was conscious and when I put it in the patient was unconscious.

[HERBIE1]

I agree Herbie. I won't bash him either and I hope that's not how my original post came off.

But I also agree that IO's are for the patient that is eitehr crashing or going there.

A unresponsive person would not warrant a IO without some additional criteria being met at least to me that is.

The generic response would be 3 iv attempts and then IO is a rule to stick to most of the time.

If I have a critical patient and I cannot get an IV in the AC or the EJ the first time then IO is the way to go.

I prefer the EZ IO drill. You can drop an IO with that device in less than 10 seconds from start of the drill to hooking up the line.

one thing to remember with those is to make sure you choose the correct needle size. Nothing worse than choosing a long needle and drilling all the way into the other side of the bone. Fluid definately does not flow then and it does cause tremendous pain in trying to flush the fluid into the bone and not the marrow space. I speak from experience here on this. Trust me.

As long as you get the right size needle then you are golden most of the time.

Taking out the IO needle I found causes more pain than putting it in if you use the drill or it may just be that when I've taken the IO out the patient was conscious and when I put it in the patient was unconscious.

We've had the IO drill for about a year now, yet I have never needed to use it. The only IO's I have done were old school and barbaric, but necessary(critical kids, and those who were in cardiac arrest). The drill seems like a great tool, but between my partner and I, even on someone who is a tough stick, we have been able to find something- even an EJ- to use.

[2Rude4MyOwnGood]

Sorry guys and gals i should have added a bit more info about her vitals and what not. Her BP was 130/88, pulse was 42 and weak, and respirations were at 10. O2 sat was 92.

I saw the medic briefly look at her arms for an IV site but quickly decided to go with an IO instead. She wasnt too happy about it once she became alert and he gave her some lidocaine to dull the pain.

Edited October 28, 2010 by 2Rude4MyOwnGood