Where to place an IV.....

[Just Plain Ruff]

I concur TC, when I went to medic school it was taught as a route of administration but significantly stressed that it was not truly a viable or safe option.

[Vorenus]

Mainlining isn`t practiced here, either, at least not in an EMS setting.

Some GPs do it though, when making house-calls.

Ultimately, it`s a bad way of giving drugs. It`s harder to make sure you`re not para, you have to be damn careful not to "slip out" while administering, plus imho, it`s only viable if giving only one med. Obiously, when facing a possible anaphylactic reaction, you still have to get a line (while having messed up the site of the initial mainline, most propably).

Plus, if you wanna draw blood (which is always handy for the hospital), it`s useless.

Edited November 16, 2011 by Vorenus

[DFIB]

I realize you were not asking me, but I am in a similar situation.

There is not a specific note in the protocols that say "No mainlining", however if I were to "mainline" a drug I could see 3 things happening:

1) Co-workers would poke fun at me for weeks on end

2) Our PCR Audit committee would question my conduct

(And if I tried to defend myself)

3) My employer would offer me remedial training on proper I.V. medication administration.

Start mainlining drugs and you WILL have a wreck! Only a matter of time before some bonehead tries to do it with D50W or Calcium and does some real damage.

I think the scenario at hand refers to extreme situations. I mean, really why would I Inject IV if I could get a line in?

What I am saying is that I agree that it is not the norm but am curious as to it's viability when other options are not available.

DFIB...the popliteal is behind the knee. Why would you want to start one there? and as for a sublingual injection?? I've never heard of that. Well except in the dentists office when he is poking me with needles in my gums but never under my tongue.

I know the popliteal vein is behind the knee. I only mention it because the original post referred to a patient with difficult venous access elsewhere. I persisted because another poster (I forget who) kept acting like it was weird and would try IO and then thought I was referring to an arterial line. I would not start there but was looking for medic’s opinion as to its usefulness in a difficult access situation.

In addition to Moby’s comment on SL injections I have heard of medics giving a sub lingual Epi injection through the bottom of the jaw in cases of swollen protruding tongue

Maybe I am missing your point.

The poster asked why services would be against Mainlining drugs, and I gave a reasonable justification.

Are you stating now, in contradiction to me, that mainlining IS an administration technique that should be acceptable in EMS based off your anecdotal one time experience?

I would excuse myself from the room in any level of provider was to try mainline a drug that can cause tissue necrosis.

I am not taking a position but simply noting that your reasons were anecdotal to say the least. Do you have any science to back up this position? I understand that not all medications produce phlebitis when properly diluted and injected. Your thoughts?

^{Paramedic mike Thanks I believe you answered my questions.}

^{Mobey _ Thanks , mike kinda gave me the info I was looking for.}

^{The reason I persisted in asking is that I have seen It done and wondered what a first world standard is and if it a practiced soley reserved for the Docs?}

^{Good discussion.}

[brainurz]

Go for the feet. My first job out of nursing school was in peds, so I stuck little feet all the time. Another often overlooked spot is the ulnar side of the forearm. Kinda awkward angle but works great if you got another set of hands to hold the arm up. If the patient is really skinny, the brachial vein works great too.

[mobey]

I am not taking a position but simply noting that your reasons were anecdotal to say the least. Do you have any science to back up this position? I understand that not all medications produce phlebitis when properly diluted and injected. Your thoughts?

Your asking me for evidince that a person holding a needle in a sick persons vein is more unstable than a secured I.V. with tubing, and therefore has an increased risk of extravasation?

I am not even going to look. In medicine we do not prove negatives. You would be few and far between to find studies that undertake risky measures of this type to try disprove things like the use of mainlining in EMS.

As a professional I am always open to changing my opinion/treatments based on evidence, but you have challenged me twice now to find evidence disproving a off-the-wall treatment/procedure, and I am not playing that game.

If you can provide evidence that mainlining is a safe meathod to practice prehospitally, or even in the ED, I will seriously look at it and adjust my standpoint as necissary.

[DFIB]

Your asking me for evidince that a person holding a needle in a sick persons vein is more unstable than a secured I.V. with tubing, and therefore has an increased risk of extravasation?

I am not even going to look. In medicine we do not prove negatives. You would be few and far between to find studies that undertake risky measures of this type to try disprove things like the use of mainlining in EMS.

As a professional I am always open to changing my opinion/treatments based on evidence, but you have challenged me twice now to find evidence disproving a off-the-wall treatment/procedure, and I am not playing that game.

If you can provide evidence that mainlining is a safe meathod to practice prehospitally, or even in the ED, I will seriously look at it and adjust my standpoint as necissary.

Good dodge. Mighty touchy for a thought long ignored.

I often attempt to get good responses that make sense from you medic guys. Not about "you have challenged Moby the paragon and are trying to make me look bad" but more "why not" because I don't know.

If you don't know or don't want to answer that is fine. I appreciate your time anyway.

.

Edited December 7, 2011 by DFIB

[Just Plain Ruff]

Short answer on mainlining, unless you are a heroin addict, you just don't do it and if you do just grab your ankles and bend over and hold on, it's going to be a bumpy ride.

[mobey]

Good dodge.

I often attempt to get good responses that make sense from you medic guys.

Not about "you have challenged Moby the paragon .

You're too smart for this childish shit.

Don't burn up you're credibility here. Re-read my post above and think about what you are asking of me.

Slinging mud like this does not suit you

[DFIB]

I realize you were not asking me, but I am in a similar situation.

There is not a specific note in the protocols that say "No mainlining", however if I were to "mainline" a drug I could see 3 things happening:

1) Co-workers would poke fun at me for weeks on end

2) Our PCR Audit committee would question my conduct

(And if I tried to defend myself)

3) My employer would offer me remedial training on proper I.V. medication administration.

Start mainlining drugs and you WILL have a wreck! Only a matter of time before some bonehead tries to do it with D50W or Calcium and does some real damage.

This is reasonable justification? And it tells us what? That your peers would disapprove with ridicule, your supervisors with remedial disciplinary training.

Some substances cause phlebitis sure.

Your asking me for evidence that a person holding a needle in a sick persons vein is more unstable than a secured I.V. with tubing, and therefore has an increased risk of extravasation?

No I just want to know if it is a viable route to administer meds if you cannot establish an IV line.

I am not even going to look. In medicine we do not prove negatives. You would be few and far between to find studies that undertake risky measures of this type to try disprove things like the use of mainlining in EMS.

Is questioning the validity of a procedure a negative?

As a professional I am always open to changing my opinion/treatments based on evidence, but you have challenged me twice now to find evidence disproving a off-the-wall treatment/procedure, and I am not playing that game.

That is the point exactly. You have given no evidence that it is off the wall or why.

Ruff, vorenus and paramedicmike made a pretty good stab at it but you haven’t offered anything and refuse even try,

You're too smart for this childish shit.

Don't burn up your credibility here. Re-read my post above and think about what you are asking of me.

Slinging mud like this does not suit you

I am not the sharpest pencil in the box by far but I know I am smart enough know a dodge when I see one.

Please save the "you are too smart for this" angle for HLPP, Flaming and the likes.

I would like to say that angle will not work on me but it did. hehe You got me to get back into a discussion that had obviously become sterile.

After rereading the thread I can summarize that:

As far as I can tell at least two posters have seen intravenous injections administered by doctors and one has done it himself with positive results. General Practitioners in Germany use intravenous injection but it is not taught to medics. None of the posters manifest having done intravenous injection with negative results but many demean the administration route as “mainlining”.

The articles I found did not refer to extravasations but to the risk of phlebitis due to improper dilution of medications specifically benzodiazepines. I can’t find a whole lot of information either in favor or against.

I ask a couple of doctor friends and they said they use intravenous injection when they want to push meds but don’t want to run an IV. They expressed no reservation except that some substances produce phlebitis when not appropriately diluted. Some medications require no dilution at all.

So my EMT level conclusion is that medications can be given intravenously by personnel whose scope of practice involves medication administration. It could be beneficial in an emergent case where an IV line cannot be established.

It seems as well that the medics participating in this thread are for the most part uncomfortable with this via of administration but have not cited a specific protocol or prohibition. Taking in account the many years of combined experience of the participating medics I can conclude that their preoccupation with the route of administration indicates that it can be done with extreme care and as a last resource. Also that although they have not done it believe it to carry hefty risk. It is not the via of choice but is not prohibited.

Thoughts?

Edited December 8, 2011 by DFIB

[Kaisu]

Just a cursory glance at the literature demonstrates to me that intra-arterial administration of drugs is NOT a good idea. Some of the studies I looked at:

Intraarterial Injection of Anesthetic Drugs

Bernard G. Fikkers, MD, PhD, Eveline W. Wuis, PharmD, PhD, Marc H. Wijnen, MD, PhD and Gert Jan Scheffer, MD, PhD

States in part “Inadvertent intraarterial injection of drugs may be accompanied by serious complications. Management strategies were discussed in a recent review (6) and also in this Journal (7). Several anesthetic drugs have been injected intraarterially by accident (Table 1). Thiopental was one of the first drugs in which this complication was described, being able to cause extensive edema, gangrene, limb loss, and even death (8).”

and further “In general, intraarterial injection should be discouraged. However, when IV cannulation is impossible and intraosseous access is deemed too invasive, intraarterial cannulation may be an option. Isotonic fluid administration is safe and drug administration should be limited as much as possible. Among the anesthetic drugs that have been injected intraarterially without adverse effects are fentanyl, midazolam, succinylcholine, pancuronium, and atropine (Table 1). Intraarterial injection of drugs not dissolved in water (such as diazepam, propofol, and etomidate) or with an alkaline pH (like thiopental, phenytoin) should be avoided at all cost.”

Extravasation injuries and accidental intra-arterial injection

Caroline Lake, FANZCA FRCA B Pharm

Christina L Beecroft, FRCA FDS RCS

“Inadvertent IA cannulation and injection may be hard to detect as the classic signs of cannula misplacement may not be apparent and the drug may inject easily with few local signs. Warning signs include:

The cannula ‘flashback’ appears pulsatile.

The flashback blood appears redder than expected.

It is possible to palpate a pulse proximal to the cannula.

There are distal signs of ischaemia.

Inserting the cannula was more painful than expected.

If there is doubt as to the accurate placement of a cannula, it could be transduced for an arterial waveform or blood sampled for blood gas analysis. However, by far the safest approach is to remove the cannula if there is any doubt that it is placed in an artery. In the case of arterial lines, a protocol should exist for the management of arterial cannulae which aims to minimize the likelihood of accidental drug administration.6

Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies

Surjya Sen, MD, Eduardo Nunes Chini, MD, PhD and Michael J. Brown, MD

Abstract

Unintentional intra-arterial injection of medication, either iatrogenic or self-administered, is a source of considerable morbidity. Normal vascular anatomical proximity, aberrant vasculature, procedurally difficult situations, and medical personnel error all contribute to unintentional cannulation of arteries in an attempt to achieve intravenous access. Delivery of certain medications via arterial access has led to clinically important sequelae, including paresthesias, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss. We comprehensively review the current literature, highlighting available information on risk factors, symptoms, pathogenesis, sequelae, and management strategies for unintentional intra-arterial injection. We believe that all physicians and ancillary personnel who administer intravenous therapies should be aware of this serious problem.

Even these few examples make clear that administration of medications intra-arterially is fraught with risk, even in a controlled environment. Some of the pictures I found were pretty graphic. Do not want to do that to a patient.