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IO vs External Jugular IV in trauma patients

51 posts in this topic

Posted · Report post

You respond to a high speed MVC, you find a patient entrapped in a SUV with signs and symptoms of shock, abdominal tenderness, and a broken left femur. Your standing orders and protocols call for vascular access on all trauma patients with signs and symptoms of shock but you and your partner can't gain IV access on his arms. What method of access do you think is best: IO access in the right anterior medial tibia with the EZ-IO or start a External Jugular IV. Give you reasons for your chosen method.

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Posted · Report post

You respond to a high speed MVC, you find a patient entrapped in a SUV with signs and symptoms of shock, abdominal tenderness, and a broken left femur. Your standing orders and protocols call for vascular access on all trauma patients with signs and symptoms of shock but you and your partner can't gain IV access on his arms. What method of access do you think is best: IO access in the right anterior medial tibia with the EZ-IO or start a External Jugular IV. Give you reasons for your chosen method.

Are these failed attempts occurring while he is still entrapped? If you can not get an IV due to positioning what makes you think an EJ would be better or less risky?

Regardless, you also seem to be implying that the anterior medial tibia is the only place to inset an IO; the humerus sounds more readily accessible.

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Posted · Report post

Are these failed attempts occurring while he is still entrapped? If you can not get an IV due to positioning what makes you think an EJ would be better or less risky?

Regardless, you also seem to be implying that the anterior medial tibia is the only place to inset an IO; the humerus sounds more readily accessible.

Let's say you can't get an IV even after you get him out of the SUV. (in my area only anterior medial tibia site IO is authorized for EMS with the EZ-IO and B.I.G. the FAST-1 can be used in the Sternal Site)

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Posted · Report post

Let's say you can't get an IV even after you get him out of the SUV. (in my area only anterior medial tibia site IO is authorized for EMS with the EZ-IO and B.I.G. the FAST-1 can be used in the Sternal Site)

Well this is still easy question.

You have to immobilize him, the collar is in the way and it is much easier to do an EJ by turning the head lateral. Since this is contraindicated in this particular MOI, I would do the IO.

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Posted · Report post

Agreed. The humerus is greatly preferred for several reasons. First, it's more accessible. Second, it's more proximal. Third, it's not as dependent. Fourth, it's much less likely to be compromised by injuries typically seen in a high speed MVA. Fifth, it's much less likely to get entangled or dislodged during extrication.

Thank God for systems that don't limit their practitioners to "protocols".

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Posted · Report post

It's a lot harder to "miss" doing an IO. Properly trained people using the EZ-IO will be able to gain quick and easy access to give fluids and medications. An EJ leaves a lot more for error IMHO. The patient will be moving probably, adding difficulty for starters. Not to mention you are sticking a needle into their neck! If by chance you miss the vein, blow it or whatever else, you are stuck holding your finger over the site. Just my thoughts...

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Posted · Report post

OK so why are we still doing EJs when we have devices like the EZ-IO?

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Posted · Report post

OK so why are we still doing EJs when we have devices like the EZ-IO?

Because EJs are still acceptable/preferrable in pts that don't need to be immobilized.

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Posted · Report post

We still do EJ's in patients who have poor vascular access due to burns, dialysis shunts, trauma to the arms etc because an EJ is a different site, which may not be affected by the reasons another peripheral IV site would be. Also, here we can only use an IO in a last effort for access where sometimes an EJ would be more appropriate.

And humeral IO would be best in that situation for all the reasons listed above.

I hope that makes sense? COld medicine may be getting to my head.

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Posted · Report post

COld medicine may be getting to my head.

Try warming it up...

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Posted · Report post

Try warming it up...

:rolleyes2::shutup:

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Posted · Report post

Cranial IO!

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Cranial IO!

Hehe... I was actually wondering how well a FAST1 might work on the forehead.

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Posted · Report post

I bet it would make a wicked cool sound.

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Posted · Report post

I find the decisions curious here, to tell the truth, unless we're assuming multiple I/O starts.

We've got a distending belly with obvious femur fracture which implies to me possible massive internal blood loss, yet each has chosen to start a single I/O so as not to be left having to manage the EJ. But what about flow rates?

I've only started two I/Os, and my delivery rate sucked. Both had B/P cuffs applied and inflated to 220mmHg, the second had, after 40cc Lido, 3 NS flushed 'slammed' into them to attempt to create a 'cavity', as I've been told that may have effected my flow rate, yet both still sucked. I've talked to many others that have started many, and they claim that they have never achieved any kind of aggressive fluid delivery rates with them. Perhaps your experiences have been different?

I believe I would utilize an EJ here despite the obvious inconveinciences based simply on the necessary flow rate needed to mitigate these injuries until extrication could possibly make other alternatives more available.

Not to mention you are sticking a needle into their neck!

I'm not realy sure of the relevence of this statement given the scenario.

Certainly no disrespect intended to the opinions of my betters, but given the scenario, I believe that I would take the EJ route. Immobilization will have to wait until I've stabilized circulation. (All of this of course assumes that physiological markers verify the above expected internal blood loss.)

Just a thought....

Dwayne

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Posted · Report post

I find the decisions curious here, to tell the truth, unless we're assuming multiple I/O starts.

We've got a distending belly with obvious femur fracture which implies to me possible massive internal blood loss, yet each has chosen to start a single I/O so as not to be left having to manage the EJ. But what about flow rates?

I've only started two I/Os, and my delivery rate sucked. Both had B/P cuffs applied and inflated to 220mmHg, the second had, after 40cc Lido, 3 NS flushed 'slammed' into them to attempt to create a 'cavity', as I've been told that may have effected my flow rate, yet both still sucked. I've talked to many others that have started many, and they claim that they have never achieved any kind of aggressive fluid delivery rates with them. Perhaps your experiences have been different?

I believe I would utilize an EJ here despite the obvious inconveinciences based simply on the necessary flow rate needed to mitigate these injuries until extrication could possibly make other alternatives more available.

I'm not realy sure of the relevence of this statement given the scenario.

Certainly no disrespect intended to the opinions of my betters, but given the scenario, I believe that I would take the EJ route. Immobilization will have to wait until I've stabilized circulation. (All of this of course assumes that physiological markers verify the above expected internal blood loss.)

Just a thought....

Dwayne

I could be wrong but it seems PHTLS taught opening the airway as you were taking cspine. Seems like they think it is a good idea to maintain spinal precautions in a high impact case, especially such as this. The caveat is I have not taken PHTLS recently so I could be misinformed.

Secondly, I have not had much issue with IO flow when placed properly... not saying you didn't, just merely noting the lack of troubles I experienced personally.

I did not rule out an EJ entirely, however have you placed many of them? It would certainly be based on that particular presentation at that time, however EJs have a high failure rate for placement when proper positioning is not used. As I noted, best positioning is a lateral movement of the head, a severe compromise of the cspine protection. Would you want me to save your life so you could be a veggie?? I wouldn't...

Now if I didn't know any better, I would say Mr.Dwayne has chose a topic to play devil's advocate cause he has been missing out on serious intelligent debates. However, I think he could have chosen a better topic...

Just sayin.

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I would define an IV as "invasive", an EJ as "moderatly invasive" and an IO as "highly invasive" when it comes to the EMS setting. To continue, why would we be placing an IO into any site if we can obtain an EJ? If a C-Collar, entrapment, etc prevent EJ use then maybe an IO can be placed. Lastly, I would pray that nobody is starting IO's simply for having access. We should only be using such means if we need to administer drugs, fluids, etc.

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Posted · Report post

Start an IO in the right femur; an EJ isint gonna do much good when we slap a collar on and drag him out into a scoop!

Also I'd rather we do a quick IO in the leg and give a little lido for the pain rather than freak this guy out by shoving a needle into the side of his neck.

FYI we use EZ-IO or the Cooks screw in; we threw the BIG out after a high failure rate

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I could be wrong but it seems PHTLS taught opening the airway as you were taking cspine. Seems like they think it is a good idea to maintain spinal precautions in a high impact case, especially such as this. The caveat is I have not taken PHTLS recently so I could be misinformed.

Actually, you are certainly well informed. Yet, in every forum I've been exposed to it emphasized life over limb. Something about a well splinted corpse, or the such.

Secondly, I have not had much issue with IO flow when placed properly... not saying you didn't, just merely noting the lack of troubles I experienced personally.

Roj.

I did not rule out an EJ entirely, however have you placed many of them? It would certainly be based on that particular presentation at that time, however EJs have a high failure rate for placement when proper positioning is not used. As I noted, best positioning is a lateral movement of the head, a severe compromise of the cspine protection. Would you want me to save your life so you could be a veggie??

Nor would I hope you'd protect a hypothetical spinal injury in the face of a realistic hemodynamic emergency. In fact...if I remember right, a large part of my thinking on this was taught to me by some big hairy friggin' dude in Afg...his name escapes me...

Now if I didn't know any better, I would say Mr.Dwayne has chose a topic to play devil's advocate cause he has been missing out on serious intelligent debates.

Heh...Ok, so you might have a point, as it is getting difficult to find a decent argument here...

However, I think he could have chosen a better topic...

Story of my life...but I'll take my chances.

Thanks for your response ol' man...

Dwayne

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Posted · Report post

I think all have valid points based on our own experiences, outcomes and training. In a situation like this, it is hard to develop a formalized opinion on what method I would choose, as I do not have a live patient in front of me to help me decide based on the numerous observations that can be made of a patient. Personally, I would probably go for the IO as it is quicker and in my experience (although limited) more reliable. I would want access ASAP to give fluids and medication if necessary.

On the topic of c-spine precaution, if the patient has a high cervical fracture then movement could end life. So as Dwayne put it, Life over Limb and by maintaining a neutral alignment on the c-spine, I could very well be preserving life.

Just my $.02 for what it's worth

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Posted · Report post

On the topic of c-spine precaution, if the patient has a high cervical fracture then movement could end life. So as Dwayne put it, Life over Limb and by maintaining a neutral alignment on the c-spine, I could very well be preserving life...

Granted, but have you used your portable xray/cat scan to determine that you have such a fracture?

I don't need such things to believe that if I have an obvious femur fracture and a distending belly that the threat of life ending hemorrhage in an entrapped pt may exist, right?

For the sake of argument let's say that you can't get an EJ without lateral movement of the head, surely in theory it sounds like it would be a bitch to do. And let's again assume that you will get 10mL/min flow with the I/O or 60mL/min flow with the EJ (not sure if that's realistic or not on the EJ, but it sounds close.)

With the above described symptoms, would you still choose to protect a hypothetical risk to life as opposed to attempting to mitigate an evident one?

I'm really not arguing for this as I don't know what the most responsible course of action would be. But I do believe that if I had this patient sometime in the next 5 minutes that I would feel the need to manage the fluids first and hope that the EMS Gods would watch out for a spinal fracture.

Also, I've only started two EJs (three attempts) and had no need for a C-collar on any of them, but I don't see the major issue surrounding an EJ and C-collar, assuming that the EJ was placed first and secured with the collar in mind. What am I missing?

And for the record Kate; I think your thoughts are worth way more than two cents...

Dwayne

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Posted · Report post

We were not there to see this patient. Maybe they were in the proper position to place an EJ. Maybe they weren't. Every patient situation is different. If a patient is in an MVC, and their head is lateral, and I see a nice vein, I will do the EJ, and I have. To protect c-spine, and the patient's head is facing laterally, do we not try to gently move it back to the proper position? EVERY patient I have ever seen, that was fully mobilized, was in anatomical position regarding their head. Now, you can't sell me that every patient fell and landed like this, or crashed their car and their body stopped in that position.

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I would define an IV as "invasive", an EJ as "moderatly invasive" and an IO as "highly invasive" when it comes to the EMS setting. To continue, why would we be placing an IO into any site if we can obtain an EJ? If a C-Collar, entrapment, etc prevent EJ use then maybe an IO can be placed. Lastly, I would pray that nobody is starting IO's simply for having access. We should only be using such means if we need to administer drugs, fluids, etc.

I agree that an IV is invasive in the the EMS setting but compaired to the use of the EZ- IO, the B.I.G., or even a hand driven IO needle an EJ is much more invasive. The risk to a patient and recovery time from an IO is almost excalty the same as that of a patient who gets an IV (having had a bone marrow sample taken from myself with a hand driven adult IO needle) the only additional risk to the patient from an IO is a fracture in the bone where the IO is placed, the additional risks to a patient getting an EJ are much more serious. I do not see a need for EMS provider who are trained, authorized, and have access to the needed equpment to do an IO to concider an EJ before starting an IO. The only time I would see the need to do an EJ when an IO is an option is after an IO has been estblished and it has failed to provide the needed flow rate for a patient in need of fluids to support their BP.

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Posted · Report post

I agree that an IV is invasive in the the EMS setting but compaired to the use of the EZ- IO, the B.I.G., or even a hand driven IO needle an EJ is much more invasive. The risk to a patient and recovery time from an IO is almost excalty the same as that of a patient who gets an IV (having had a bone marrow sample taken from myself with a hand driven adult IO needle) the only additional risk to the patient from an IO is a fracture in the bone where the IO is placed, the additional risks to a patient getting an EJ are much more serious. I do not see a need for EMS provider who are trained, authorized, and have access to the needed equpment to do an IO to concider an EJ before starting an IO. The only time I would see the need to do an EJ when an IO is an option is after an IO has been estblished and it has failed to provide the needed flow rate for a patient in need of fluids to support their BP.

How do you figure an EJ is more invasive than an IO? With an EJ you are putting in in a peripheral, superficial vein, much like when you go in to AC. An IO is being drilled through someones bone, down into their marrow.

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How do you figure an EJ is more invasive than an IO? With an EJ you are putting in in a peripheral, superficial vein, much like when you go in to AC. An IO is being drilled through someones bone, down into their marrow.

I am looking at patient recovery, risk vs reward, and stress on the patient. An EJ has far more risk then a peripheral IV (an EJ is not a peripheral line pre many textbooks b/c of it's flow to the heart, many textbooks put EJ just below central lines as far as vascular access and time to action i.e. Transdermal->Oral->Sublingual->SQ->IM->IO->Peripheral IV->External Jugular IV->Central Line->Interacardiac) EJs are more invasive b/c of the risk to the patient and the after care required. If you give someone an IV or IO you can take it out and send them home, EJ you need to monitor them for 12-24 hours after removal b/c of the additional risk of an EJ.

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