IO on Living Person

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.

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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:

INTRAOSSEOUS INFUSION
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
situations:
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.
CONTRAINDICATIONS:
• 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.
PROCEDURE:
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.

COMPLICATIONS:
• Infection
• Compartment syndrome
• Subcutaneous extravasation
• Clotting of marrow in needle
• Osteomyelitis/cellulitis

PEARLS
Sites:
Should be used on sites in accordance with manufacturer recommendations and guidance from local medical control.
Introsseous,
• 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.

12 Comments

  • Jon says:

    This IO driller is very nice. I’ve been trying it out on my ambulance and worked nicely.
    I still prefer the Bone Injection Gun since it is easier to use, does not require any batteries or other accessories and is much lighter and convenient.
    check out their website:
    http://www.waismed.com
    Jon

  • Kelsey says:

    I had to try the bariatric IO needle for the first time awhile back. It was a really bad crash with a woman who arrested shortly after we got there. Our protocols have us work traumatic arrests if we witnessed them arrest with no obviously fatal trauma.

    I couldn’t feel any landmarks on her knee because of the excess adipose tissue, so I immediately reached for the bariatric IO while my partner attempted his second line.

    I pushed the needle through her skin until I connected with the bone, and then I let the drill do the work. I didn’t put any extra pressure on the drill, and it did one revolution before the needle bent at a 45 degree angle at the hub.

    I guess it makes sense because the metal needle is so much longer, it doesn’t take much pressure to make it bend. I tried again at the same site with the regular adult IO, and with a lot of pushing, I was able to get it to stick in her tibia.

    Have you used the Bariatric IO before? Have you heard of this problem with them?

    • medicscribe says:

      No, you’re the first person I know who has used one. One of the services I oversee just got the needles in. We haven’t recieved them yet at my service. I bent a couple of the old hand held Ios. No such problem yet with the EZ-IO. I f I ever get the bariatric needle, I will think about the danger of the needle being easier to bend.

      Thanks for the comment and Happy New Year!

      Peter

  • EMS Chick says:

    My county recently started carrying these but the flight medics that we see have had them for awhile. The first time I saw one used was on a conscious patient and the memory has stuck. The patient fell and had fractures on each extremity. The flight medic told the patient it would hurt a little, like a pinch. He starts drilling, the patient starts screaming, my jaw drops as I had no idea what to expect, and the ambulance gets quiet. The flight medic apologized saying it was necessary and I took his word for it since he had way more training than me but let me telly ou it’s something I still remember 4 or 5 years later.

  • Jon says:

    We have them at the 2 community 911 services I work for. Love them, even though we rarely use them. I have no adult IO device at the primarily transport part-time job (which, if I guess correctly, is the local branch of the same place you work for).

    EZ-IO has other approved sites, including the top of the humerus. That doesn’t seem to be specifically disallowed in the protocols you posted. Here in PA, I’ve seen them done in the shoulder for several reasons… one being Pt’s size.

    And there is always the FAST 1 IO:
    http://www.youtube.com/watch?v=v_G6I27XTj0

  • Talk about a barrier that’s hard to get over; that’s mine! I too have used an IO on numerous unconscious patients, but do not look forward to the day where the situation presents and I have to actually consider it as a life saving measure.

    What’s even worse, we don’t have protocols for pre-infusion Lidocaine. Just no looking forward to that day at all!!

  • medicmarch says:

    Company I work for has carried the EZIO for about two years now with the Adult and Pedi bits. We have EMR and over the past year I’ve used the EZIO 13 times (pretty high cadiac arrest rate down here) with 12 successes (the one I missed on bent – I applied a little bit too much pressure on the drill). It’s really a boon, so easy to use. Have had three ROSC, one ROSC survived to discharge (EZIO used). Met patient a week later. She had a good sized bruise and small puncture but other then that no ill effects related to the insert.

  • medicmarch says:

    PS – we do have lidocaine written into the protocols for use on awake patients – I’ve not had to use it yet, however.

    A friend of mind had volounteered for placement during a demo. She stated it was about 4/10 on insertion…of course, there was no flush, AND she had had a baby about 8 weels earlier, so I’m betting her pain scale is different from mine…

  • medicscribe says:

    Thanks for the comments.

    I don’t have any experience with the bone gun or any other of the new IOs aside from EZ-IO.

    Interesting about meeting the person and seeing the bruise. I have heard about people demoing it, but never them egtting the fluid.

    When we whip the gun out, the cops who are our first responders always cringe.

    Thanks again for all the comments.

    Peter

  • Madeline Miller says:

    I had this procedure in the ER. Had gone in with chest pain and it quickly led to cardiac arrest. I remember very little about this experience except I definitely remember the pain in my knee. I don’t think I would ever want it again.

  • Susan says:

    I hope this will ease your concerns. I am a nurse and have only inserted an IO on a cadaver. But I had one placed in me due to severe hypoglycemia and dehydration. The EMT and paramedic both seemed traumatized because I screamed but I assured them that I do not remember the insertion or D50 administration. After removal, which was painless, it was a little sore only when I flexed my knee. So, don’t think about the scream but only that you saved their life. That’s what I remember – I’m alive.

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