I was unable to attend the annual Australian Trauma Society meeting this year (truth be told, my membership lapsed and I’ve been busy with other projects recently). But in these days of FOAMed and use of social media to connect, I was able to follow vicariously via the twitter feed from #Austrauma. One tweet, admittedly not direct from the Austrauma feed, but from one of it’s speakers – caught my eye.
Now it’s hard to argue with Karim Brohi – if you’ve not met him, he’s the chap who kicked off perhaps one of the earliest ever FOAMed sites – the thoroughly excellent trauma.org site (which turns 20 years old in 2015!). He’s well-regarded as a trauma expert, international speaker and leading trauma researcher. He’s also a nice chap and interacts with others through the twittersphere – whether trauma guru, student, rural doc or paramedic. I reckon he’s a chap who believes in striving for quality improvement across the board – his words from smaccGOLD still resonate re : use of audit to improve systems and lead to innovation, such as implementation of REBOA “you have to sweep the floor, everyday”
So I was surprised by this statement from Brohi regarding the demise of the IO. Use of IO has taken some time to percolate down; I remember as a junior reg (so maybe 10 years ago) being admonished for placing an IO in a shut down 14 year old s they were “only to be used in children 9 years and under”. Nowadays there is no age limit – and we’ve moved from the old fashioned Cooks IO device to alternative device, the use which is taught in APLS, ATLS and other entry-level courses. Heck, we’ve even (finally) got them into small rural hospitals here in Oz!
I think Karim was purely referring to the utility of IO in a tertiary level resus bay, where rapid administration of blood is needed – the need to use pressure to infuse can cause to cell lysis, negating any advantage.
So is the IO route really dead?
I think not. Imagine a patient entrapped. Access through the window allows access to the humeral head and placement of an IO to facilitate extrication via administration of agents such as ketamine. In a resus bay, placement of an IO allows early administration of fluid and drugs, for both analgesia & procedures such as RSI.
Sure there are other routes – intranasal, intramuscular, rectal….and I’ve even placed an IV in the corpora cavernosa once (well, it communicates with the vascular space – just don;t run an adrenaline infusion through a line placed in the willy)
Placement of a subclavian swan sheath or peripheral rapid infuser catheter is ideal if rapid administration of warmed fluids is needed. Indeed I think RICs should be available not just in resus, but anywhere where people bleed – theatre, labour ward and prehospital.
Here’s the infamous ‘AC/DC & Barry White rapid infuser mashup’, which Scott Weingart chose for inclusion in Roberts & Hedges Emergency Procedures in Emegrency Medicine as a video demo of how to place a RIC…
We still teach venous cutdown on ATLS in the animal lab – although the last cutdown I saw was over a decade a go in a difficult ED resus, requiring attempts at both saphenous and brachiocephalic veins.
Options for IO devices?
There are a few devices out there. Access points include humeral head, proximal & distal tibia, ischial crest and sternum (the latter is for FAST-1 only, not EZ-IO or BIG).
IOs such as the EZ-IO reportedly allow rates of 125ml/min, with the intrasternal device (mostly used in military) quicker still. remember to WARM FLUIDS so as not to contribute to the lethal triad.
YouTube always seem to have some videos of these devices being put in – I admit that I’ve had an EZ-IO put in, which I didn’t find at all painful (and I am a bit of a needlephobe). However having 10ml of saline pushed through the device hurt big time! Some recommend administration of 1-2 ml of lignocaine prior to running in fluid (remember to use a pressure bag or dedicated person using three-way tap). Still hurts like a MoFo though!
Old fashioned Cook IO needle – these are now mostly gathering dust in the corner of EDs or have been removed completely. They were the device that we trained with on APLS a decade ago. Sadly it was relatively easy to push through the bone – and into the palm of your hand if supportng the childs lower limb.
The Bone Injection Gun – a spring-loaded IO device, which is designed for ease of use. Our hospital purchased these (no consultation with clinicians) and I can report that the experience has been disappointing. despite training, we have had nurses sustain sharps injuries by deploying the wrong way around. Locums unfamiliar with the device have struggled. One of the major problems is that the recoil of the spring can be taken up by the hand-forearm unless wrist is “cocked and locked”. Of course there is no tactile feedback either.
Although much cheaper than the EZ-IO device, the fact that failure rate is both means that 2-3 may be used per insertion attempt (anecdotal data from local experience), I would avoid the BIG, and instead recommend…
The EZ-IO device – this is simple to use. Sadly the drills are crazy expensive, as are the needles – however they allow easy insertion, give tactile feedback and are the device with which most clinicians train, making them the sensible choice. I ended up doing a deal with the health department, whereby purchased my own drill for prehospital and ED use, with needles being supplied by the Health Department.
And lastly, the FAST-1 device – this is an intra-sternal device favoured by the military (which kind of makes sense in combat as victims limbs may be blown off)
You can read a review of these devices HERE
Intraosseous Devices for Intravascular Access in Adult Trauma Patients Day M.W. (2011) Crit Care Nursing 2011 31 : 76-90 doi: 10.4037/ccn2011615
“It’s blood they bleed, so it’s blood they need”
For now, I will be keeping my EZ-IO handy – I appreciate it’s not brilliant for rapid administration of fluids inc blood, but the ease of use and ability to rapidly administer analgesia or sedation/RSI drugs makes it a useful tool in the armamentarium…
…and if all else fails, there’s always a 14G needle and a strong arm to gain IO access!
2 thoughts on “Is the IO really dead?”
I agree with John Hinds comment about limited benefit in a mature tertiary system. But we don’t all work in these systems. I have frequently used IO for rapid access in trauma in the trapped patient, as well as in the sick medical patient who needs urgent “central” access for inotropes etc, where it is either impractical or inappropriate to place a CVL (e.g. primary or “scene” medical response). Equally, many small medical facilities either do not have the skills or the volume to maintain competency in placing central lines, whereas IO skills are easily learned and maintained.
My experience is that the flow rate through an IO is highly variable, however this can be minimised by ensuring an adequate (20mL min) forceful saline flush prior to infusion of drugs or fluids. I have had PRBC flow freely through a humoral IO without a pressure bag; often pressure is required though – this is not necessarily a contraindication as almost every aeromedical service in the world would routinely use pressure bags for infusion of blood due to the issues of altitude / pressure / lack of height to hang infusions.
I am also a big fan of the RIC, but this requires familiarity with the seldinger technique – again not necessarily a common skill in EMS or smaller medical centres. Additionally, you want to make damn sure you have another working line as its not that difficult to prang the vein trying to insert a RIC. And of course you must already have (2x) peripheral vascular access for a RIC to be of use…
When you are “between a rock and a hard place” forget about IO or RIC or a time consuming cut down at the ankle.
Go for gold, use a scalpel, make a transverse cut through the skin starting at the scrotal / labial fold and extend laterally 6 cm. Use your fingers to blunt dissect fat and lying just below/within the fat is the greater saphenous vein, cut the tip from the giving set tube at 45 degrees, nick the vein with the scalpel and feed the purged giving set tube into vein around 6 cm, turn the giving set on while you tie the tube to skin.
This will take around 30 seconds from first cut until fluid is running and you get better flow rates than a RIC as there is no flow obstruction at the end of the line.
I am sure there are plenty of theoretical reasons not to do this procedure but I have used it on multiple occasions with excellent results in some very ugly situations.
I first learnt this trick while I was doing what I thought at the time was a textbook ankle cut down, an ex military surgeon pushed me out of the way telling me I was “killing the patient”, he had a line inserted and running flat out in under 30 seconds. I haven’t killed a patient since!