The patient is morbidly obese and obtunded. I look at him with his tongue protruding from his mouth and think, if he stops breathing he is going to be impossible to tube. We try to stimulate him, but barely get any response from a deep sternal run.
On our way to the hospital, we look for an IV. Nothing. Then I remember we carry the EZ-IO.
I have used the EZ-IO about eight or nine times, but always on cardiac arrests — patients who were more or less not feeling any pain. We can use it on living, and even awake patients in extremis, and while I know of medics who have done so, I have not encountered the situation yet, but this I am thinking may be that time.
Now I was very skeptical of the EZ-IO when it first came out. I have always been very proud of my IV skills and felt that people might jump to do an EZ-IO and neglect a findable peripheral vein. Surely, the IO had to be more harmful to the patient. Then two things happened. One, I read that infection rates for IOs were far less than they were for peripheral veins, and two, I used it during a code for the first time — on a one legged diabetic — and was astonished about how quick and easy it was to put in. While I still look for peripheral veins on codes, if I can’t find one right off the back, I have no hesitation about going for the drill.
But drilling an IO on a live person – that is a barrier that is tougher to cross.
My preceptee and I discuss the possibility and decide to go for it. My preceptee picks his landmark on the proximal tibia (just below the knee) and starts drilling. While EZ-IO makes a larger bariatric needle for large patients, we don’t carry them yet. This needle is just spinning in the man’s fat. Fortunately I have had this situation before. We reposition the angle and lean in hard on the drill. By applying pressure we find the bone. The needle drills in and finds anchor. My preceptee asks if he should give the lidocaine dose before hand. The lidocaine dose is a pain-control measure for conscious patients. While the drill itself causes only minor pain, they say it is the fluids being pushed that really hurts. This guy reacted to the drill with only the faintest of groans. “Not necessary,” I say. “He’s unconscious.”
I prepare a saline flush while my partner spikes a bag. I push the 10 ccs of fluid and from out of the depths of unconsciousness, the patient screams and nearly comes off the stretcher. I keep pushing and he keeps screaming. It is a good thing it only takes four or five seconds to push the saline. As soon as I am done pushing, he drops back to unconsciousness.
I think maybe we should have given him the lidocaine (Although that likely would have hurt just as much pushing the saline in). Maybe next time.
We hang the bag of Saline and wrap a blood pressure cuff around it to get the fluid flowing. It drips in a slow, steady rate. We call the hospital and let them know what we are bringing in.
In the ED, they are pleased we have IV access. There is no “What?! You drilled a live person?!” reaction. So I guess they have seen it before.
Still I am thinking as far as IOs on living people, if it caused an unconscious person that much pain, I can’t imagine how painful if might be to an awake patient. If I have to drill another living person, I will certainly use the lidocaine, and will likely search just a little bit longer for a useable vein.
As an aside, this all raises the issue of pain relief for the unconscious. Our guidelines, while quite liberal for pain control, don’t allow pain relief for anyone with a GCS of 12 or less. When patients go the OR and are operated on, they are not just knocked out; they are medicated with analgesics before hand because even though unconscious, they continue to feel pain and pain can be quite harmful to the body. What about the groaning patient with multiple fractures? A topic for another day.
Here are our regional IO Guidelines:
The following guideline is to be utilized for FDA approved intraosseous access devices only. You should follow the specific manufacturer’s guidelines for the insertion rocedure.
INDICATIONS: May be inserted on standing order for the following:
Adult (> 40 kg) & Pediatric (3 – 39 kg)
1. Intravenous fluids or medications needed and a peripheral IV cannot be established in
2 attempts or 90 seconds AND the patient exhibits any of the following:
a. An altered mental status
b. Respiratory compromise
c. Hemodynamic instability
d. Status Epilepticus unresponsive to IM or rectal medication
2. IO access may be considered PRIOR to peripheral IV attempts in the following
a. Cardiac arrest (medical or traumatic).
b. Profound hypovolemia (Shock) with altered mental status.
c. Patient in extremis with immediate need for delivery of medications and or fluids.
• Fracture of the tibia or femur
• Previous orthopedic procedure (knee replacement) or IO within 24 hours
• Infection over insertion site
• Inability to locate landmarks due to either significant edema or excessive tissue
Note: If contraindication exists, utilize an alternate insertion site.
1. If the patient is conscious, explain the procedure and provide the rationale for it.
2. Use appropriate body substance isolation equipment.
3. If the patient is conscious, prime the extension set with 2%, preservative-free Lidocaine* and leave the syringe attached (up to 50 mg Lidocaine total).
4. Identify the insertion site.
5. Prep the site with betadine** or alcohol.
6. Prepare the IO needle.
7. Stabilize, insert the IO needle and remove the stylet.
8. Confirm proper placement (aspiration of marrow; flushes freely without extravasation).
9. Connect the extension set and flush with 2% preservative-free Lidocaine*:
a. Adults 20-50 mg
b. Pediatric 0.5 mg/kg
10. Rapidly flush with 0.9% NaCl:
a. Adults 10cc
b. Pediatric 5cc
11. Start infusion utilizing a pressure bag or BP cuff (if pressure bag unavailable).
12. Secure the catheter and tubing.
13. Attach identification wrist band, notify receiving facility staff and deliver removal instruction form to treating physician or nurse.
14. Frequently monitor IO catheter site and patient condition.
* If the patient is unconscious or allergic to Lidocaine, prime the extension set with 5-10 mL 0.9% NaCl.
** Betadine is preferred (if patient is not allergic to iodine). If time permits, swab three separate times in an outward, circular motion utilizing a fresh applicator each time.
Note: Paramedics must have attended a medical control approved, device-specific in-service and demonstrated competency prior to utilizing an IO device in clinical practice.
• Compartment syndrome
• Subcutaneous extravasation
• Clotting of marrow in needle
Should be used on sites in accordance with manufacturer recommendations and guidance from local medical control.
• Complications are infrequent (0.6%) and consist mostly of pain and extravasation.
• IO flow rates are typically slower than with IV catheters. Use a pressure bag or pump.
• Insertion of IO needles in conscious patients causes mild-moderate discomfort and is usually no more painful than a large bore IV.
• Infusion through an IO line may cause severe discomfort for conscious patients and preservative-free lidocaine should be administered.
• Onset of analgesia with lidocaine typically takes approximately 1 minute and lasts 40 minutes to 1 hr.
• The most common side effect of lidocaine toxicity is seizures.