IO Contraindications

Now, there are also some issues associated with I.O. use by EMTs and paramedics in the field. We don’t want to use I.O. access in any patient with any kind of fracture in that extremity because obviously if the bone is broken, especially in the lower leg, you can’t tell which of the two bones is broken necessarily. You just might know you have a fracture because of some deformity. You don’t want to administer fluids or medications into a bone that has a hole in it other than the one you put in it. So if the bone is broken, you’re just going to be pushing the fluids out into the extracellular space and into the interstitial spaces of the tissues outside of the bone and it’s not going to get into the vasculature, so you don’t want to put it into a broken bone. Think about multi-system trauma patients, being very careful about trauma in-between your location and the center core structures of the body.

If you’ve already tried to place an I.O. device in that same site or leg, you don’t want to be putting it there, go to the other leg if you can. If there’s any history of bone cancer or bone disease in this patient, you don’t want to be treating this particular patient this way unless you’ve achieved medical direction first. So call in to your doctor. Usually it’s an isolated location. If they have had a history of bone cancer in this particular extremity you’d want to use the other extremity, but you talk to your medical direction and follow your own protocols as always. I shouldn’t have to tell you that but I’m going to anyway.

Patients with osteoporosis history should not be getting IO access as a primary IV access point. This is a degenerative bone problem. People with bone issues, with fragile bones because of deficiencies or disease or chronic issues are also not candidates for I.O. access in most cases. If patients have some kind of a problem with that lower leg, if they have an infection of the lower leg, we probably don’t want to be opening the bone to that infection, so we want to consider not using that as well.

IO Site Preparation and Devices

Once you found your site, because of the risk for infection just like we have with any I.V. placement, we want to make sure we’re very carefully cleansing the area first. We’re going to make access to the device, to the leg, or to the site. Once we selected our site and cleaned it, we'll gain access with an approved I.O. device. A lot of the agencies are still using this old hand-crank models where you just basically holding it in your hand and twisting it in. These things are brutal.

I’ve never had to place one, but I practiced a lot on chicken thighs which is what we used a lot in our area. If you haven’t heard that trick, I urge you to go out and buy a family pack of chicken thighs. You can get some I.V. fluids and practice—put your gloves on and practice placing in the bone of these chicken thighs. They’re actually pretty close to what you might feel when placing in a young child. You can get an idea of how it pops in to the marrow space. Then if you color your I.V. fluid with some food coloring, you can actually squeeze it in and infuse it and you can actually watch it color the tissues of the chicken thighs and then you can cook it up and have a nice barbecue later with your green or blue-colored chicken thighs infused with saline solution.

So you want to make sure that you practice and understand how this works. You want to clean your site carefully. You want to use your device in an approved manner. So if you are using one of the new I.O. devices like an I.O. drill, the EZ-IO comes to mind. It’s one of the ones that actually have my hands on and practice with although we don’t yet have it in our system, but you want to follow your device guidelines for how to use it properly, how to attach your I.O. and then attach your I.V. to the needle catheter.

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Find more EMS news, commentary, tips, skills reviews, and more at the MedicCast EMS Podcast web site.

IO Fluids and Meds

Let's talk a little bit about I.O. access in general. You can administer I.V. fluids both crystalloid and colloidal fluid solutions. You can administer most medications. Most that are available for I.V. use can also be administered via I.O. access. I don’t know in the EMS arena of any medications that can’t be administered I.O. in the situation where you would have I.O. access. Also of course, blood products can be administered directly via I.O. access. It’s a non-collapsible area so you’re not going to have veins collapsing or causing issues. If you can get your needle in there, it will work.

When to Use Intraosseous Access

When would we use I.O. access? I mean we are going to be drilling in to a person’s bone here, and this is something we don’t want to do lightly. This should be only used for your most critical of patients. Just like I talked about administering therapeutic shocks to patients needing cardioversion, I don’t think you should be using I.O. access for any patient that would be able to complain about it.

That means that they should be unconscious or dead. We shouldn’t be using this for any but our most critical patients—our patients who are in cardiac arrest or are seriously injured with a multi-system trauma or something like that.

IO Placement and Landmarks

There are also some things we need to think about as far as placement of our I.O. access. I.O. access points typically are thought of, especially in children, as the proximal end of the tibia. There’s a flat surface, a few centimeters distal to the tibial tuberosity. There’s also a location farther down on the tibia, the medial malleolus (on the inside of the ankle). Just proximal to the medial malleolus you can find I.O. access there, and in older children and adults that may be a better point of access because up near the top of the tibia, it tends to become much thicker and harder up there as children age.

There are other access points such as the sternum. In some devices you may see that sternal access is allowed. In fact in many agencies, they’re starting to look at the proximal humerus as another access point for I.O. access. The key thing to think about here is because we’re talking about such critical patients, and in fact patients who may need CPR, if they don’t already have CPR in progress, we don’t want to put our device in such a location as to inhibit the effect of administration of CPR or to inhibit our ability to administer medications or deal with airway access and still do the other things we need to do around the torso and the head. So that’s one of the advantages of using the lower extremities.

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Find more tips and information for EMTs, paramedics, and EMS students at MedicCast.com

One of the the items covered was some review of the history of IO access.  Like so many advancements in emergency medical care, IO access grew to maturity during a time of war due to advancements in trauma care of injuries sustained in battle.  Paramedics and other advanced care providers in EMS today owe this skill to research and studies dating back over 60 years.

IO History

Over at the MedicCast site link above you will a very interesting PDF download link that I found having to do with the origins of I.O. access during World War Two and before. I.O. access was first investigated in the 1920’s and 1930’s when the understanding of the circulation nature of bone marrow was first kind of really described in detail in some medical journals.

Anesthesiologists were considering it as a good resource for them to administer anesthesia, and it was found that I.O. access was as faster than other routes for medication administration, in some cases even faster as a route of administration when compared to intravascular access—I.V. access.

In World War Two, in fact, as this was a brand new thing, it was found as reviewed documents from World War Two that there were four thousand documented instances of I.O. access being used in war time care of soldiers that were severely injured. Again, as a route of access for someone that is severely injured, critically injured, or in cardiac arrest there is really nothing like it.

It makes sense when you think about it.  You don’t have to try to find a vein or tie it up. You cleanse your general site. You’re talking about hitting the bone marrow in a bone that is several centimeters in diameter. You’re just going to find that landmark insertion point. If you can get to the center of the bone with your I.O. device, you’re going to hit marrow and you’re going to be able to rapidly get access into the vasculature and be able to administer medications and fluids, including blood products.

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More on IO access coming up soon here at EMTPodcast.com or check out the whole I.O. Paramedic Skills episode at MedicCast.com.  The MedicCast is a weekly online radio program or podcast for EMTs, paramedics, and EMS students.  Each episode features news, commentary, tips and more just for EMS providers at all levels.

Here is a transcript of some of the discussion and review information.  You will find more links and information at the episode link above.

EMS Podcast Episode Transcript

Let's move on to this week’s Tip of the Week and this week’s Tip of the Week.  This week let's talk about intraosseous IO access and EMS providers in the field. Our good friend Jerry Barrett down in Australia sent in this tip idea in and it’s something I really haven’t covered a lot of in recent shows.

I think it’s probably been over a year since I’ve covered anything about I.O. access and it’s something that we should be aware of. It’s an alternative to our normal EMS I.V. access points that is available to us in our most critical patients and provides us a quick and easy route of medication administration, fluid bolus and just basic patient access that we can use when time is against us. We shouldn’t be fiddling around. We’re trying to find I.V. access in a patient who may have little or no blood pressure present to lift a vein enough to visualize or palpate.

The American Heart Association has discussed IO access for cardiac arrest patients in their most recent guidelines for ALS treatment. They say that I.O. access should be considered. We shouldn’t be playing around with getting I.V. access in a patient with difficult venous access points.

This is something that we should review and recover and understand because even if you’re a BLS provider, you should understand why I.O. access is such an important point to us in the ALS care arena, and be prepared to help us get the sites available, and protect those sites adequately once we have access. Because obviously once you’re going to the trouble of getting I.O. access, you don’t want to have anything dislodged or cause an issue with that I.O. access point because, clearly, it’s a point of access that we don’t want to have to do, again, if we don’t have to.

So what do we want to talk about? I found some good resources for I.O. access and there’ll be links in the show notes, so I urge you to head over to the MedicCast blog, find the “Podcast” category—“EMT Podcast” category there—and look up the links for this week’s show notes because you will be able to find a lot of other information that I’ve been able to discover for you.

Stay tuned for more on IO access for EMTs and paramedics here and at the MedicCast EMS Podcast.