IO vs. IV in a drug overdose situation

[mobey]

I have had some experience in IO, so I will give my opinion as well.

First: No, I do not use it as 1st line in any adult pt.

However, I have used it on both concious, uncouncious, and cardiac arrest victims, and in my opinion it is not that brutal. I think there is a stigma with drilling a needle into a bone, but it really is not that bad.

To be honest, I would use it waay before an EJ based on risk of complications AND patient comfort.

The first time I used one was on a pneumonia with aspiration/resp failure. She needed deep suctioning in the worst way so I decided to RSI her. She was a GCS of about 10. I drilled in the needle and she did not flinch at all!

Once I infused a NaCl preload of 10 ml though she frickin near got up and ran!!

At this point, lidocaine can be introduced, and numb the area...... I used narcotics of course, since I was RSI'ing.

As you can tell, I am pretty comfortable with them, and in the situation presented, given there were NO veins palpable/visible, I may start one.

Now, don't be jumping down my throat about IM narcan. If I get an Uncx OD they are getting an IV/IO for more reasons than just narcan.

[prescott medic]

Actually, if there is a respiratory insufficiency, IO insertion is approved for drug overdose. Howevery choosing the greater tubercle of the proximal humerus would be the most beneficial. Anything administered through a tibial IO will take around 6 seconds to reach the heart, but the tibia is a painful site. The humerus is almost pain free, and with a Lidocaine bolus (40mg), the infusion pain is virtually gone. I highly recommend the EZ-IO, and have had great success with it.

[Just Plain Ruff]

IO as first line? No

I'll try to find a vein first but if I cannot then I'll go IO

I don't think that the drills are barbaric but the old center punch style ones are definately not for the squeamish.

I do not have any issue dropping an IO as I have worked through the generic pitfalls with those I've already done and my last two were without issues.

I also do know that if you don't get that Lidocaine in then you are going to have a angry or hurting patient.

I have seen ED's give vicodin or percocets to patients who had IO's removed for the pain management aspects.

Anyway, it's all good and all relative. The sicker the patient the more likely that I'll do an IO.

Let me ask this question

Do your protocols say you transport a patient who had an IO started?

[HERBIE1]

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.

Thanks for the additional info.

Only other question I would have would be pupillary response, nystagnus, etc. Yes, narcotic OD's present with constricted/pinpoint pupils, but only if a narcotic is the lone culprit.

Sometimes it's difficult to play Monday morning QB, but given this information, I see absolutely NO need to start an IO on that patient.

My take-

Give the Naracan IM, and while you wait for it to kick in, supplement her respirations, give O2. Although bradycardic( which in my experience is very unusual for a straight heroin OD), this person is still not what I would call "critical", and in need of immediate IV access via an IO.

What I would be aware of is a possible drug combination. These days, many OD's are actually due to more than one drug ingestion- whether it's intentional, or the desired drug happens to be laced with something else. I would also be VERY careful about giving too much Narcan, since there is a real possibility the effects of the heroin are masking another- possibly much more dangerous drug like PCP. Once you remove the sedative effects of the naracotic, you may be left with a patient who is now wide awake, and in a full blown PCP rage. I can say from personal experience, that is an extremely BAD situation.

[mobey]

Sometimes it's difficult to play Monday morning QB, but given this information, I see absolutely NO need to start an IO on that patient.

My take-

Give the Naracan IM, and while you wait for it to kick in, supplement her respirations, give O2. Although bradycardic( which in my experience is very unusual for a straight heroin OD), this person is still not what I would call "critical", and in need of immediate IV access via an IO.

This must be a difference in regions or something.

If I showed up at the hospital with this pt, with no IV/IO, I would probably have some explaining to do.

If they are going to get an IV in-hospital, they are going to get it prehospital.

Just an observation

[2Rude4MyOwnGood]

Actually, if there is a respiratory insufficiency, IO insertion is approved for drug overdose. Howevery choosing the greater tubercle of the proximal humerus would be the most beneficial. Anything administered through a tibial IO will take around 6 seconds to reach the heart, but the tibia is a painful site. The humerus is almost pain free, and with a Lidocaine bolus (40mg), the infusion pain is virtually gone. I highly recommend the EZ-IO, and have had great success with it.

The medic gave a Lidocaine bolus shortly after she "came back" because she complained of pain in the insertion site. After that her main concern was that they cut her only bra into pieces.

IO as first line? No

I'll try to find a vein first but if I cannot then I'll go IO

I don't think that the drills are barbaric but the old center punch style ones are definately not for the squeamish.

I do not have any issue dropping an IO as I have worked through the generic pitfalls with those I've already done and my last two were without issues.

I also do know that if you don't get that Lidocaine in then you are going to have a angry or hurting patient.

I have seen ED's give vicodin or percocets to patients who had IO's removed for the pain management aspects.

Anyway, it's all good and all relative. The sicker the patient the more likely that I'll do an IO.

Let me ask this question

Do your protocols say you transport a patient who had an IO started?

The protocols state that any patient who has received a medication must be transported. She refused care but the PD was there to ensure that she came with us, since she had received the Narcan. Im not sure about protocols regarding transporting all patients with an IO, i was just a ride-along on the call so im not up to speed on the protocols.

Thanks for the additional info.

Only other question I would have would be pupillary response, nystagnus, etc. Yes, narcotic OD's present with constricted/pinpoint pupils, but only if a narcotic is the lone culprit.

Sometimes it's difficult to play Monday morning QB, but given this information, I see absolutely NO need to start an IO on that patient.

My take-

Give the Naracan IM, and while you wait for it to kick in, supplement her respirations, give O2. Although bradycardic( which in my experience is very unusual for a straight heroin OD), this person is still not what I would call "critical", and in need of immediate IV access via an IO.

What I would be aware of is a possible drug combination. These days, many OD's are actually due to more than one drug ingestion- whether it's intentional, or the desired drug happens to be laced with something else. I would also be VERY careful about giving too much Narcan, since there is a real possibility the effects of the heroin are masking another- possibly much more dangerous drug like PCP. Once you remove the sedative effects of the naracotic, you may be left with a patient who is now wide awake, and in a full blown PCP rage. I can say from personal experience, that is an extremely BAD situation.

I didnt get a look at her pupils since i was trying to stay out of the way unless the medics wanted me to do something. As i said above, i was just a ride-along on the call. It would have been very helpfull for me to get a bit closer to the patient but by this time there were 4 other EMS providers besides myself in the back of the unit. I didnt want to get in anybody's way.

Im in my 1st Intermediate semester and was there mostly to observe.

[Timmy]

I like to work with the KISS (keep it simple stupid) principle (must be the Australian in me, were all pretty laid back), benefits outweigh the risk, less invasive the better ect ect.

The risk of osteomyelitis (greatly increased in the pre hospital setting), the grumpy OD who wakes up swinging then walks off into the sunset with the IO still insitu and all those further risks are very real, why do we need to put a patient at risk when a less invasive procedure is just, if not more effective than jumping to battle stations.

It’s a bit like watching the surgical and medical registrars ‘debate’ patient care, very amusing, indeed, anyway…

[HERBIE1]

This must be a difference in regions or something.

If I showed up at the hospital with this pt, with no IV/IO, I would probably have some explaining to do.

If they are going to get an IV in-hospital, they are going to get it prehospital.

Just an observation

I was speaking in the context of the patient presented in the OP.

If a person is otherwise stable and you suspected an opiate OD, IV access is not mandatory if they have no peripheral veins. If I gave the person IM Narcan and their status improved, I see no reason to start an IO, and the hospital would have no problem with it. To me, an IO is not the same as an IV in terms of potential risks, harm, or possible complications to the patient. An infiltrated IV site is not as serious as if you have a missed IO. I need a darn good reason to start an IO- my patient would need to be critically ill, and the patient in the original scenario does not rise to that level in my opinion.

We simply say we tried an IV x's 2, etc, or saw nothing viable to even shoot at, and that is a perfectly acceptable outcome. Now obviously if the person is unstable and decompensating, then IV/IO access becomes imperative.

[DwayneEMTP]

Now, don't be jumping down my throat about IM narcan. If I get an Uncx OD they are getting an IV/IO for more reasons than just narcan.

I wouldn't think of it...Sounds reasonable...

But I'll tell you what I just can't let pass....

However, I have used it on both concious, uncouncious, and cardiac arrest victims, ...

Wouldn't that be both + 1? What kind of screwed up language do you freaks use in your part of the world!

This kind of stuff just burns my ass.....

Dwayne

Just sayin'.... :-)

[mobey]

I wouldn't think of it...Sounds reasonable...

But I'll tell you what I just can't let pass....

Wouldn't that be both + 1? What kind of screwed up language do you freaks use in your part of the world!

This kind of stuff just burns my ass.....

Dwayne

Just sayin'.... :-)

Hahaha... Love it.

Here, is this better?

"However, I have used it on both concious, and uncouncious, cardiac arrest victims"

That's right, concious cardiac arrest victims..... Tell me my CPR is ineffective