IO vs. IV in a drug overdose situation

[HERBIE1]

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.

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.

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.

Understood. Hope you experience more things that make you think. You learn the most from those.

[2Rude4MyOwnGood]

Understood. Hope you experience more things that make you think. You learn the most from those.

I definately learned a good bit on this particular ride along. I was fortunate to be tagging along with 2 medics who were very eager to teach me. Both were young guys, very bright, and never made me feel like i was in their way.

[HERBIE1]

I definately learned a good bit on this particular ride along. I was fortunate to be tagging along with 2 medics who were very eager to teach me. Both were young guys, very bright, and never made me feel like i was in their way.

Glad you had a good experience with your preceptors.

I never understood the mentality of some providers who did not like having riders or students. Most of the time these types were clowns, cutting corners, and not providing proper care. I would much rather teach someone the right way to do the job than for them to learn bad habits from day one. The didactic part of the learning process is "easy"- it all depends on how much you are willing to absorb and retain. The hard part comes when someone needs to show you how and.when to apply that knowledge, and the little things that make you a good provider.

To me, a good trainer/preceptor/field training officer is worth their weight in gold. They determine the caliber of the future providers, and whether or not we will eventually gain the respect and pay we all deserve.

[ambodriver]

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.

I agree---lots of heroin where I am and it is most often snorted. I usually can find something on the venous users where they can't reach. An IO is a bit of a stretch, then again I was not there so I do not know the details and cannot comment!

[zzyzx]

I actually came very close to doing an IO on drug OD some time ago. The call came in as a cardiac arrest, and when I got there, the patient was apneic with a pulse. The first-in medic had already given Narcan IM and of course they were bagging her. We did not see a vein anywhere, with both of us looking. She did not respond to the IM Narcan after quite some time into the call, so we gave it IN as well. I was expecting a quick response as from my past experience with IN's, but she did not respond at all and was still a 1/1/1 and apneic. I was about to do an IO when she finally began to respond. If I had not had this call, I would also have said that it seems overkill for a medic to do an IO on a drug OD, but there are situations where it is appropriate.

[CSAR_MEDIC]

Brutal not the way we use it. The Pn associated with the IO is from the change in pressure in the osseous and can be delt with using 0.5 mg-1.0 mg/kg of lidocaine. All that said I WITHOUT being there I belive I would not have done the same thing with the information I am being presented granted we are dealing with a poly pharmaogical overdose there other ways to deliver narcan that are less invasive. IO are amazing I am a big proponet of themhowever with the above information I feel it was not necessary .

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

[p3medic]

We deal with a lot of heroin around here, 99% get IM or IN narcan and they walk to the truck. If there are other findings that suggest a more complicated case that I feel I need vascular access, and peripheral IV isn't available, than I'm more than happy for the IO. I would not place an IO simply as a route to administer narcan.

[2Rude4MyOwnGood]

Thanks for all of the replies!

I ran this case by some of my instructors and most of them didnt have any strong feeling that in IO wasnt necessary. They seemed to think that it was a good idea due to the fact that IM Narcan takes a bit longer to take effect.

IOs are used often in my area, since the EZ-IO guns arent nearly as "barbaric" as the manual method, and provide a quick route to administer meds.

[Paramagic]

With regards to IM naloxone having a slower uptake: this is not necessarily a bad thing. So long as adequate ventilation is ongoing there is all the time in the world to administer narcan. In fact I personally feel that this is a better route to take. Oxygenate well, let the narcan work slowly and you have a much happier patient at the end of it all. In 13 years I have never had an overdose come up angry or swinging. All the angry/swinging/puking ones I have seen or heard of seem to be a result of having a hypoxic head and a sudden blast of IV narcan to ruin their day.

I like to take my time, utilize the opportunity to give my student or BLS crew some time to do some manual airway management (which is difficult and often poorly done) and bring them up slowly. That and treating the patient with respect by not cutting up their best (only?) clothes means that the overdoses I wake up tend to shake my hand and thank me for saving them.

[Aussieaid]

An infiltrated IV site is not as serious as if you have a missed IO.

Not sure what you mean by this? An infiltrated IV is going to have exactly the same effect as a missed IO - fluids and medications going into the tissues instead of the vein or osseous. It will just be in a different location. And just for the record an infiltrated IV can be extremely serious depending on what drugs have been extravasated. I have seen people lose limbs from infiltrated IVs.

Found an interesting ScScandinavian retrospective IOstudy.

Edited November 24, 2010 by Aussieaid