HERBIE1 Posted November 14, 2011 Posted November 14, 2011 EJs are allowed for traumas and codes, IOs are only for the most critical patients. That is our setups here in my area. I was thinking that the back of the arms would be a good place. I am a paramedic student in a place where we are only 5-10 minutes from a hospital so we have very short transport times. edited to make an addition to of my sentences to make it understandable. Not sure of the make up of your crew- ie how much help you have and their certifications, but we also have short transport times in our system. There is nearly always time for an IV, but I would certainly not waste an undue amount of time. Start it enroute to the ER PRN, unless you need immediate access for medication or for fluid resuscitation. This is a good example of where communication between providers is critical. Who does which tasks when, what are the priorities, what is the patient's condition, etc- all things that need to be worked out.
DwayneEMTP Posted November 14, 2011 Posted November 14, 2011 FE2, I'd be curious to see your protocol for EJs being allowed for traumas and codes only. I'll be willing to bet that because many are afraid of them that that is the only time they are used, if then even, so that's what you've heard, but I'll bet you dollars to donuts that that isn't what your protocol says. Read for yourself, don't take the word of those that are afraid to use them. It made me batshit crazy to watch medics bring in very sick patients, all aflutter, "We couldn't get an IV after multiple attempts!" to see the big ol' fat EJ sticking up without a mark on it. I happen to love IVs in the legs when appropriate. And EJs too. But EJs/IOs/Nasal intubations all have at least one thing in common in my experience. The majority of the paramedic world can come up with the most amazing excuses not to use them. Not because they're inappropriate or not valuable, but because they're scared of them. Make sure you're using all of the tools in your toolbox when you need them. Even those that you're afraid might make you bang you knuckles. Dwayne
tcripp Posted November 14, 2011 Posted November 14, 2011 Oh, I like this topic. I've yet to do an EJ and I've done 2 IOs on live patients with one of them being called "over zealous". I used it on a CHF exacerbation patient. Not to hijack this thread too much, what is your criteria for using the more invasive access?
paramedicmike Posted November 14, 2011 Posted November 14, 2011 Like others have said, you get a line where you can. Hands and forearms are good. Feet and legs are good. EJs are good. IOs have their place. I'm not sure why the concern over contractured arms. Blood still returns even with your arms bent. Unless there are existing circulation issues, which your physical exam should help you identify to some extent, I wouldn't worry about it too much.
DwayneEMTP Posted November 14, 2011 Posted November 14, 2011 Oh, I like this topic. I've yet to do an EJ and I've done 2 IOs on live patients with one of them being called "over zealous". I used it on a CHF exacerbation patient. Not to hijack this thread too much, what is your criteria for using the more invasive access? Do you include EJs in the more invasive category? For I/O my last protocol was great I thought. "At least two unsuccessful attempts with future successful attempts appearing unlikely." (paraphrased from memory) I think that's not a bad way to go...Though I do believe that I/Os are often under used. We once had a gunshot victim that no one could get an IV on without it blowing. I posted about it once. I think we had 10-12 attempts by mulitiple providers, each one blew almost immediately. We eventually ended up at the ER without an IV (I was a student then), a pt with a softball sized chunk of hamburger out of his left tricept, mid humorus powder, hypotensive to the point that he was moving from AAOx4 to unresponsive. The ER was eventually able to place two 22s before getting more aggressive. How easy to place one or two I/Os and be done with it? I didn't know enough then to question it, so I'm not sure why it wasn't considered. And this has been a few days ago, so perhaps it wasn't an option for them then. Dwayne
tcripp Posted November 14, 2011 Posted November 14, 2011 (edited) Do you include EJs in the more invasive category? Wasn't...but I guess I should have. Would you attempt the EJ (counting it as one of your two) before you went to IO? For I/O my last protocol was great I thought. "At least two unsuccessful attempts with future successful attempts appearing unlikely." (paraphrased from memory) I like that as a guideline. Ours is a little more simplified and reads as follows: Intraosseous therapy should be initiated in those patients who present in serious or life-threatening circumstances when Intravenous access is unobtainable, and patients who present in cardiac arrest. Any patient who requires fluid resuscitation (i.e., dehydration, burns, trauma etc.). Any patient who requires intravenous medications. Any patient in cardiac arrest. Leaves it way open for interpretation of "unobtainable" and "serious condition". Toni Edited for layout only Edited November 14, 2011 by tcripp
romneyfor2012 Posted November 14, 2011 Posted November 14, 2011 I would always go EJ before IO. I believe IO is overused due to poor IV skills of the medic. I am not saying that it does not have a place in your treatment algorhythm, but a patent IV is almost always superior to IO. Now before the OP asks, I would not put an IO in the patient he referenced (bedridden with contractures) except in some very rare and serious circumstances.
systemet Posted November 14, 2011 Posted November 14, 2011 I think the issue here occurs more when a provider opts to go to an EJ or IO when there are other acceptable routes for medication administration, or there isn't a clear indication for the IV / IO, e.g. * pain management, which can usually be given IM or SC * to give D50W when glucagon is available but hasn't been used * to administer anticonvulsants, instead of going IM * for relatively small amounts of rehydration in a patient that isn't suffering serious dehydration * IV/IO narcan, etc. Unfortunately there are people out there who don't exercise good judgment and seem to be motivated by performing "cool" procedures.
paramedicmike Posted November 14, 2011 Posted November 14, 2011 This obviously wouldn't work for fluid resuscitation as outlined in the OP, but intranasal administration of certain medications is a viable alternative to IV placement as well.
2Rude4MyOwnGood Posted November 14, 2011 Posted November 14, 2011 Since hypovolemia is an issue with this patient, after a few failed attempts at a peripheral IV, im reaching for the IO. Its quick, easy to use, and again....quick.
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