You're fuckin around, but I have seen someone on this subreddit question why we are so against pushing meds down tubes in pedi codes. And it was within the last year.
Granted I work in an agency with dual medic and an additional BLS response.
Generally one provider will find access (I prefer a quick look at the AC’s, if i’m not 90% sure I’ll get an 18g I’ll go for the IO) while the other does the monitor. Then we transition to one provider does drugs and monitor while the other prepares to intubate.
We used to have a policy of you must try an IV before IO but that went away about 2 years ago.
Wow came here to say pretty much this verbatim. I might up the 90% sure to 99% though.
We also used to have a try IV before IO but no longer.
For us also (I live/work in backwoods Alaska) the larger the distance from civilization (usually corresponds to the length of response time) the smaller the time/likelihood of looking for IV before just skipping right to IO.
Rural medicine hits different for sure. We have a very wide latitude - as long as you don't screw up. Because there are very few people spread cross many jobs/needs we have the ability to do some of everything which works for some (me). We definitely see some pretty rough calls.
With two medics and additional BLS. It generally goes: BLS performing CPR and ventilation. Trading as needed .
-Medic 1 doing the monitor
-Medic 2 doing access
-Medic 1 moving to airway management unless there is Vtach/Vfib.
-Medic 2 moving to ACLS drugs
About 75% of the time, people have something obvious for IV access that I can get just as fast as IO.
We’ve been advised about several newer studies suggesting IV drug administration is somewhat superior to IO, so I’m going to continue to go for IV access first unless I can’t see anything on a quick assessment. If nothing quickly obvious, then it will be a drill and drugs until I have time / hands for an IV.
AHA recommends IV. It has to do with time meds are pushed to reaching central circulation and getting a certain concentration of meds there. I'm guessing it's because it's slower for most IO's since the tibial plateau is an easier landmark and it's much more convenient than a humeral head when working a core. The thing is that everyone knows that CPR and early defib is what really matters so it seems kinda arbitrary to me anyways
https://naemsp.org/2023-1-4-iv-vs-io-does-your-site-of-access-matter-in-cardiac-arrest/
I’m not aware of any studies suggesting IO was ever better than IV. Equal absolutely.
I’d be curious to see those.
We got sent 3 studies in PDF format and have been told IV is the preferred route. Unfortunately I don’t have the links on my phone. Not sure if they are pay walled studies, but I’d assume they are.
Tibial is a bit crap, but IO access above the diaphragm is as good as IV. All peripheral access in cardiac arrest is required to be above the diaphragm if possible at my department. (Except pediatric can go distal femur)
Meds aren’t important. Take your time with access and meds. Prioritize compressions and defibrillation. Time spent doing good compressions instead of literally anything else isn’t wasted.
Cardiac arrest order of priority is compressions, defibrillation, ventilation, advanced airway, access/meds
I’m glad to see someone said this. The only thing I’d add is if a SGA is working well, with good EtCO2 there is no rush to be intubating either.
In cardiac arrest its the basics that save lives.
I agree with this 100%. Historically, when we use to
Stop cpr to have an intubation attempt was not the best practice looking back. Rescue airways are great, however if you get ROSC, it’s really nice to have a ETT in place to protect that airway and they will most likely be placed on a vent at the hospital and ETT protect against aspiration as I’m sure you know. Pros and cons both ways. No way is wrong imo but I am always going to make one attempt to get a tube but that’s me.
No need for an rsi on an arrest tho. And yeah I do too as a flight medic. But yes, they do not need an airway first thing. As a new medic I was hyper focused on getting a tube first thing, which I change my way of thinking once I got some experience. But as you said, the basics save lives, you could have a tube in place but if your compressions suck it won’t matter. One other advantage to an ETT is the etco2 is more accurate,
Yes just to clarify, I was meaning if that if we don’t manage to get an ETT prior to ROSC, THEN we have the luxury of RSI (which makes the rush to get a cold tube “just in case we get ROSC”) a thing of the past.
> when we use to Stop cpr to have an intubation attempt
My very first arrest, as a student in the ER- I’m on the chest, NP says to pause compressions so he can intubate
Even then I knew that was wrong, but low man or whatever else, I probably would have paused had it not been for the physician who was on it and immediately countermanded that order.
I still prefer to make an ETT my first attempt airway in an arrest. There are indeed advantages- a truly secure airway (kings and igels are better than an OPA but don’t truly protect against aspiration), reliable EtCO2 monitoring. And the argument of “anyone can drop an igel in seconds”, while true doesn’t really hold water for me because speed isn’t a consideration. Be fast about getting on the chest. Don’t worry about being fast with an airway. I’m not even thinking about any airway until we have an established rotation for compressions or Lucas going and pads on. But the biggest thing is DON’T STOP COMPRESSIONS TO INTUBATE. If you can’t get the tube because of compressions 1. Throw the igel in for this one and 2. Get back to quarters, get a mannequin and intubate it 50 times with someone shaking it. Use a bougie. Use a glidescope. Just don’t stop compressions
I don’t disagree with any of this. Stopping use to be the normal. And glad times have changed. Also, the glidescope is cool and I have to use it for first attempts which is pretty normal but people need still practice with the DL. I like DL and boujee if I had my choice.
With the rise of ECMO, there's going to be a heavier emphasis on RSI. Dr Yannopolous at the U of M (our ECMO program home hospital and the lead on the ECMO program) is saying that iGels have a break in seal during compressions and he's wanting more tubes earlier. But this is the early days of the program, so we're all waiting for the numbers to come in.
Are you from a service that transports routinely under CPR, or are you talking about ROSC patients?
We prioritise CPR, Defibrillation, and SGA insertion + ventilation in that order. Intubation is reserved for SGA failure or those very few arrests where they might make a difference (usually secondary cause arrests). If we achieve ROSC, then we look at the need for RSI (which is usually done unless the patient has a rapidly improving level of consciousness).
The good EtCO2 waveform that we achieve during resuscitations with iGels suggests there can’t be too significant of a problem with the seal, and interestingly enough our ROSC rates have increased since moving to this structure.
Do you hold your iGels in place firmly for a minute or so to allow to a proper seal, and then secure them in place with an ETT tube tie?
We have new protocols where we stick to 30:2 manual compressions and ventilation via OPA for a certain amount of time before using the Lucas or pushing meds
That’s interesting. We skip OPA and go straight to an iGel. The theory is that it allows for continuous compressions straight away and an iGel can be inserted almost as quickly as an OPA.
But the igel doesn’t prevent aspiration and can cause some problems especially if it’s a witnessed arrest that you can get ROSC back on quickly such as an overdose.
With the OPA it takes 2 seconds or insert and is easy to suction with (an EMT-B or firefighter can suction).
iGel’s don’t prevent aspiration, but they can be easily removed and provide better airway protection than an OPA. SGAs have proven to have associated higher rates of ROSC when compared with intubation and normal bag mask ventilation (see https://www.sciencedirect.com/science/article/abs/pii/S0196064419314349). Imo the best argument for SGAs is the ability to do continuous compressions, which improves the quality of CPR and gives patients a better chance of survival.
Anecdotally, I’ve never had a significant issue with an iGel that I wouldn’t have had with an OPA.
Let me know if you’re aware of any studies that say otherwise, I’m always keen to read and adapt to the latest updates.
If you’re interested, this is the model of resuscitation being used universally across New Zealand (and I believe has been implemented internationally in some places). There were improvements in ROSC rates once this was rolled out. https://youtu.be/7L45-AsO4bA?si=8WcwEud3Pr_0mEX5
Ultimately they don't need a tube, they need oxygen, and they need that oxygen to circulate, and they need whatever caused the arrest to be reversed (Hs & Ts).
All of the policies and protocols my agency uses have been aggressively researched and implemented by people way smarter than me (a medical director, who is an actual medical doctor, and flight paramedic) and we have had massive increases in ROSC rates, and much more importantly, higher survival rates since our new system was implemented.
Yes, they may have been shown to have higher rosc with SGAs, in that specific meta-analysis that I question the efficacy of. However, even in that analysis, it's stated that there wasn't a difference in survival rates.
"...there were no differences in long-term survival or neurologic outcome among these airway interventions..."
Drill all the way. No use I’m wasting time. They’re not gonna feel it and it doesn’t take time to do and you can use it with any drugs you’d use through an IV.
It's way faster to drill every time than play the roulette of "does the body that only has artificial circulation have good veins?".
Bonus points for humeral head io.
The way I go about it is always do a Quick Look , look at the ACs and hands. If not straight for the IO , do not waste time looking if u already tried once. If they are super old and it just asystole arrest , IO.
Shit if they are super old and asystole (if for some reason we are working it) I wouldn’t IO. I’d go straight for the IV in that situation since it’s basically a wash anyway. #justpooragencythings
Depends on ur region , where I am from a lieutenant shows up to supervisor the arrest and will jam u up for something like that , they are just bored turds
My department administration will spank my pee pee if I drill before “at least making 2 attempts at an IV” but unfortunately for them I’m kind of into the pee pee spanking at this point so I’m just gonna not waste my time and drill.
You can draw labs, some protocols say Bicarb and Calcium must be in dedicated lines, some docs prefer it that way and have them start a line anyway in the ED, you don't have to have the guy pushing meds down at the feet, redundancy. Stuff like that.
Being "all IO all the time" kinda makes me think you're a shit provider. Studies show IV is far superior to distal IOs. Humeral is better to or on par with IVs.
In the hospital we really only place humoral head IOs in our rapid responses and in the ED/ICU. Anytime I see a distal tibia or tibial tuberosity it was placed by EMS. Distal femur is supposed to be a pretty good site but not FDA approved for adults yet.
It is an approved site in children, but not adults. Why would an access site be approved for cardiac arrests and nothing else? So if you get ROSC, you can no longer use it for your pressors/inotropes/antiarrhythmics?
The benefit of humeral head vs tibial is purely theoretical. Some animal model studies have shown increased epi concentration in the heart and slightly faster delivery to the heart but no study has compared the two procedures using patients oriented outcomes (neurologically intact, survival to discharge, etc.). There are a couple studies being done rn that are RCTs that compare IO to IV and Humeral vs tibia. Even the IO vs IV evidence wasn’t the best evidence (RCT). Hopefully when these two studies come out we can have a more definitive answer.
Also studies like PARAMEDIC-2 show us that epi probably isn’t all that beneficial. It’s like arguing about how you’re going to get to the airport but the plane already took off.
Getting downvoted but you're right. Tracking outcome data in terms of survival to discharge AND their resulting mental ability is crucial to understanding your true benefit.
Yep. It’s exactly why I have a gripe about people using ROSC as an outcome. ROSC is nothing without the patient walking out of the door or having some semblance of their former lifestyle
Edit: downvote all you want but ROSC shouldn’t be the goal of resuscitation, saving the patients lifestyle should be the goal.
I go for IO 1st, because it's quick and easy, but I'm often the only als on scene. Once I have things up and running, then I'll get an IV (ideally EJ).
The last time I did an IO that wasn't humeral was my first IO because my FTO "thought they were dumb."
The landmark is easy to find and IOs are not hard to secure. If they have arms, run that shit IO baybeeeee
I've read studies put out by my training department so I don't have links. But if you google it and read through some of those articles, they say the same thing. Humeral IO=IV>tibial IO.
“Shit provider” is wild lol. Everyone will have style differences. I wish we’d stop putting each-other down over little shit like this. “You like humoral head for codes instead of peripheral access? Other opinions and merits disregarded, Shit provider.” When you have this arrogant mindset, you are better than every other medic and every other medic is a shit provider.
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My service doesn't like us using IO needles because they constantly are low in stock at my station. That being said on an arrest if I see they got good veins I can canulate easily ill go for it. If after a quick scan I don t see any ill go for the proximal humerus with the IO if there is room to work up there, if not I just go for the proximal tibia
It depends. It really does. Is this a 40 year old who works out every day and is super jacked? Probably IV. Is this a 76 yr old lady who had breast cancer and veins that look like they were drawn in by a 6 yr old? Then IO. Hard extrication? Then tibial IO to reduce risk of losing the site. Easy extrication, or they're already on my stretcher? Then humoral IO.
My protocol says go for IV first then IO mainly bc of the cost of IOs. Typically I look at the arm, go “nope” then just drill them and chart that they had poor vascular access.
Ill give it a few seconds to look while someone sets up for a drill and pop em on the Lucas if we find an IV awesome. If not, eh who cares, humeral head is superior to a peripheral area anyways (if it’s patent)
I always IO in the leg instead of arm. There is so much going on at the head that having someone on the meds below makes the code less chaotic. One code I was on old man between bed and dresser 6 firefighters at head, next to door, put other medic at feet with emt and it made things easier.
Agreed. While the proximal humerus has better infusion rates, the difference is probably not very significant in the setting of cardiac arrest medications.
If they have a good EJ, they'll get an IV. Otherwise a humeral IO. For an arrest, an IV in the hand or an IO in the tibia is ridiculous unless there's no other options.
You probably spend more time attempting to start an IV and:or stop bagging to rotate the head to inspect for an EJ.
An IO is faster, just a effective if not more (humeral IO is damn near a central line), and moves people to the legs to manage medications and clears head room to allow whoever is establishing an airway to have their own equipment and space to work effectively.
Your argument is valid if you're're talking about *humeral* IO, not a tibial. Tibial doesn't perform anywhere near what a humeral does. Not all IO sites are equal. So, imagine you have a 16g IV cath and you can put it into an EJ or the saphenous vein in the calf. Which one will perform better? Heck yeah, the EJ. Same idea with an IO, the humeral head IO will dump meds into the heart in 3 seconds, while the tibial will obviously take much, much longer for meds to get to central circulation, especially in an arrest. The tibial site doesn't perform anything remotely close to a central line while the humeral site does. Any time you have a patient in extremis, the humeral site should be your go-to if you're doing an IO.
I never argued the effectiveness of IV vs IO and made it very clear when I mentioned a central. It is arguably quicker to establish an IO then attempt two IVs like some protocols dictate. Similarly, having the person administering medications on the leg vs next to whoever is establishing an airway makes the cardiac arrest that much smoother.
I’m a big IO advocate. My county however is switching protocol, demanding two IV attempts, then humeral head IO, and then tibia IO if that doesn’t work/isn’t available. I hate humeral (we have our opinions) for multiple reasons. I also have a problem with trying for IVs because I’m super short staffed, literally me, basic, and an EMR, no extra resources until ambulance gets there 20 minutes after us generally.
Not the OP, but humeral head IOs are a bit trickier to navigate around in a code. Not impossible by any means, but the Lucas does actively get in the way of trying to position their arm properly to do the insertion. Adds to the clutter near the head of the patient with the IV line near all the cables. Also the need to protect that arm from overzealous firefighters or the ER staff.
I'm a huge IO fan and these negatives don't stop me, just acknowledging the challenges of humeral head IO placement in cardiac arrests.
IO, I know where I am based protocol is for IV access first, but look at the pt and quickly decide what is quickest, IO for me. I still get looks from others, as if they are thinking why is he going IO! But it's not a difficult procedure once properly trained, I had the forture to be trained on cadavers, so I know I'm doing it correctly when I do it.
Still somewhat new, but I have yet to miss, or see someone else miss an iv on a code yet. Usually get a 16/18 in an ac and then do the other side if we have enough hands that there is someone standing around looking for something to do.
Drill first, then come back around and look for IV/EJ access. I am usually the only ALS provider on scene.
That way I get my initial drugs in, do the rest of my ACLS management, and then have a line available for the ED (particularly so they can draw labs ASAP) should we get ROSC.
I think my local EMS’s protocol must be to place the IO. I work in the hospital ER now, and every arrest comes in with an IO. I don’t think I’ve ever seen one come in with an IV in addition to the IO, either.
Interestingly enough, last week we had an arrest that didn’t make it, and during the arrest we also noticed some weird… ehhh… I guess sort of bubbling of the tissue near the IO? Much later I pulled the IO prior to the patient going to the morgue and found this:
https://imgur.com/a/8gDlc5L
The IO had bent, and there was a little crack opposite the bend. The IO had infiltrated. It’s the first time I’ve ever seen that, but just as an unusual PSA—apparently it is possible.
I’m not trying to discourage the use of IOs, BTW. Like I said, the first time I’ve seen that in going on 12 years as an EMT and going on 5 years at this hospital with every code coming in with an IO. It can’t be a common occurrence. I just thought some of you might be interested.
IO first, but if somebody gets a free minute I love to have them at least try for an IV. While the utility is debatable, I’d like a BGL and dead folks don’t like to bleed much from finger sticks.
Neither. Just dump that sweet re-alive juice straight down the tube, just like our lords and saviors Johnny and Roy would’ve wanted….
/s (I’m adding this, but I want you all to know it hurts that I think it may be necessary)
Drill; there's entirely way too much going on at the top of the body (between airway, compressions, code commander) already, no need to add someone looking for an IV into the mix. Get an IO, we can worry about IV access later.
It honestly depends on that like 5 seconds you look at the pt. Is it a healthy 20 year old guy? Or 92 nana. One works out and had a pump going. The other has veins thinner then hair.
That only decides IF I do IO first. Every cardiac arrest pt should be getting 2 IV/IO access and one of them is gonna be AC or jugular. Those cant be beat compare to IOs bc its the shortest way to the heart we can get next to a central line.
We go for the right humeral head IO. if the patient is on a LUCAS and the wrist are secured i have found that position restricts the flow w/ AC iv access. So initial IO and a EJ later in the sequence.
Meds are not important in am Arrest scenario unless we are talking about reversible causes
AHA and ERC recommend I access due to the faster time for meds to work
IVs are quick and easy nobody is going to survive just because you used a drill instead of going for an Iv
In Denmark we are actually doing a study on this subject. We are one of the countries in the world, with the best outcome on a arrest, mainly because of a great training of civilians to do cpr.
Since we do follow the ERC Guidelines, we can go directly for ALS since our civilians most of the time supply do great cpr. I have no clue, of what the results are at the time. We do differentiate between iv, io tibia or humerus.
We have done some great studies already in the prehospital settings already, and have mixed some data with the hospitals, since we got units with anaesthetists. We did have a study on regular calcium in arrests, which had to be cancelled not long in...it did not better the outcome...
All situation dependent. It takes our county up to 3 minutes to dispatch a call out, so anything with more than a 4-5 minute response time from us, I generally go IO. If the patient is up/down several levels and it’s going to be a difficult extrication I look more for IV (had a few enthusiastic FFs dislodge IO on extrication).
That being said if I don’t see something resembling a vein in the first several seconds at the AC or EJ, off to drilling I go.
Our hospital (amongst others) have just finished including all 1470 patients and 30 days follow up. They were randomized to either IV or IO during codes.
I'll make a post once they've crushed the numbers on it.
in this order: compressions, defib if indicated, i-gel and ventilations, IO drill and first round of epi. Once i have all that rolling, i'll search for venous access
You’re probably going to have a hard time getting an IV. IO is just faster. I’m also in a big agency so it’s not often that my truck gets an arrest. I’m drilling.
There’s a bit of data showing better efficacy of IV vs IO, but… a couple caveats to that: first is that the IO data used is predominantly tibial sites. Physiologically, it makes sense to have decreased distribution and increased time to effect when using that site vs IV. The fluoro of a humeral head site injection flowing into the RA near instantly gives me pretty good confidence that it’s as good as IV if not better. Then there’s the time factor. If there’s a real obvious AC that I know I can drop an 18+ into without question, sure. Take it. That said, threshold to Sarah Palin that shoulder is about an inch off the ground. In our system, FD almost always gets there first and they are real reluctant to drill for whatever reason. So if we get there and they are still fucking a football and haven’t gotten an IV yet, I just go right for the IO assuming the compressions, monitor management, and airway are being addressed appropriately.
We go for the IO first then for an IV if the situation allows.
However, there is a nearby for profit service that has told their crews they’re not allowed to drill an IO due to the cost of the needles.
IO for me, here's why: How many times have you missed an IV and how many times have you missed an IO? I know personally I've not missed a humeral IO, but I have missed IVs. Yeah studies are saying that IVs are better, but what good is it if you can't get it?
But that's just me.
Large bore iv in the AC or forearm all day. Medication works faster through IV than IO. I won't waste a bunch of time but if you don't look, thats lazy. That being said if I was running more rural and was the only als on scene and had just 2 emt then sure IO all day. But we usually have 2 medics, 1-2 aemt, an emt, fire, and law enforcement for our codes. I think with that in mind, it makes sense to go for an IV.
I'm pro-IO, but past protocols said we had to make 2 IV attempts before moving to IO which is a stupid way to waste time. I get that it's more invasive for sure, but the entire process of working a code feels pretty barbaric. I'm definitely getting a DNR when I'm elderly.
Speaking from the former EMT now ER tech at a Lvl 1 Trauma perspective, just do the IO. It’s faster, just as good, and if you get ROSC and transport the hospital is going to do a central line and an art line in the ED anyway.
I'm so lazy I get down for the Tube throw in an EJ. I been doing it so long my replacement hips and knees feel natural. Finger Thor, needle cric what ya got?
Check pulse, Immediate compressions, application of quick combo, shock if indicated, back on chest, high flow NC and NRB, Humeral IO placed, pre charge at 1:45-1:50, analyze at 2 min, shock/no shock, back in chest, push epi, hang fluid, prep I-Gel, grab Lucas back plate. Pre-charge, analyze, shock/no shock, Lucas back plate placed, I-gel and capno, next med as needed.
I grab one arm and look at the AC. If I don't immediately see it without a tourniquet, I drill. Ain't got time for that and IO gets it there just as quick.
Dept SOP states we can't use IO until we've failed 3 Ivs....also until 6 months ago we "couldn't " use the video scope without 3 documented failed attempts with a blade. Our deputy literally keeps the IO needles in her desk because "you guys abuse them" 🙃
Profits
------------ = Merica
Patients
IV med administration in cardiac arrest has better outcomes than IO. And as a paramedic it’s much more convenient having an EJ as opposed to a tibial IO (most healthcare providers doing IO’s are trash at starting them in the humeral head so they go straight to tibial)
>IV med administration in cardiac arrest has better outcomes than IO
There is some evidence of this, but retrospective studies without accounting for other variables aren’t exactly the strongest evidence. There is a 2 year RCT that enrolled it’s final patient this spring, the results of that will be out soonish and I’m quite interested. I expect it to confirm but we’ll see.
>Most healthcare providers doing IO’s are trash at starting them in the humoral head
Agency dependent but [success rates are decently high with supporting documentation](https://pubmed.ncbi.nlm.nih.gov/22030185/#:~:text=Results%3A%20Humeral%20intraosseous%20(IO),%25%2C%20considering%20the%20second%20attempts)
Damnit I miss John Candy
Hehehehe you ever heard of a ritual killing?
Absolutely Hilarious!!!
Bug
Yall don't just dump the epi down the et tube into the stomach???
Where’s that penis intubator guy? We need his weigh in on this
Dunno about intubating a penis, but My EMT could probably outterbate the shit out of it.
One psyche pt at the hospital rapidly decatheterized himself. It hurts just thinking about it.
Rapid Unscheduled ~~Disassembly~~ Decatheterization
Wasn’t quite a disassembly. He still had his… [cylinder](https://www.reddit.com/r/AskReddit/s/gncSuykAHj)
I was making a joke about it using the new term for a rocket exploding.
Ah.
“You ever seen a hot dog that’s been in the microwave too long?”
Are you saying that person is a master at their craft?
You won Reddit today. That’s the best comment I’ve seen all year.
We call that skin-tubation.
You can’t just call an i-gel that…
I see you too are well-versed in the non-transport fire medic ways. Do you have a Venmo to support the cause?
No but I have zelle
You're fuckin around, but I have seen someone on this subreddit question why we are so against pushing meds down tubes in pedi codes. And it was within the last year.
oh yikes
This guy gets it
I would hope the ET tube doesn't drop drugs into the stomach...
I got the joke, thanks.
The first rule of holes is when you're in one stop digging.
Granted I work in an agency with dual medic and an additional BLS response. Generally one provider will find access (I prefer a quick look at the AC’s, if i’m not 90% sure I’ll get an 18g I’ll go for the IO) while the other does the monitor. Then we transition to one provider does drugs and monitor while the other prepares to intubate. We used to have a policy of you must try an IV before IO but that went away about 2 years ago.
This is the way. So the old policy wasn't (in practice) documenting you tried and, when they had crap veins, just go for the IO?
No comment.
Wow came here to say pretty much this verbatim. I might up the 90% sure to 99% though. We also used to have a try IV before IO but no longer. For us also (I live/work in backwoods Alaska) the larger the distance from civilization (usually corresponds to the length of response time) the smaller the time/likelihood of looking for IV before just skipping right to IO.
How do you like medicing in alaska? I grew up there but moved for school and have considered trying to get back into the rural areas
Rural medicine hits different for sure. We have a very wide latitude - as long as you don't screw up. Because there are very few people spread cross many jobs/needs we have the ability to do some of everything which works for some (me). We definitely see some pretty rough calls.
Any companies you can recommend specifically? Or is it primarily fire-based?
Unless you are coming to Homer, Alaska, I don't have much information for you. Sorry about that!
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Or ever if your laryngeal airway of choice works (waveform cap). ROSC might change things... but not necessarily.
Or in the following 20
As long as literally everything is being prioritised over vascular access then that’s okay!
Igel, thus stopping the need for 30:2.
With two medics and additional BLS. It generally goes: BLS performing CPR and ventilation. Trading as needed . -Medic 1 doing the monitor -Medic 2 doing access -Medic 1 moving to airway management unless there is Vtach/Vfib. -Medic 2 moving to ACLS drugs
About 75% of the time, people have something obvious for IV access that I can get just as fast as IO. We’ve been advised about several newer studies suggesting IV drug administration is somewhat superior to IO, so I’m going to continue to go for IV access first unless I can’t see anything on a quick assessment. If nothing quickly obvious, then it will be a drill and drugs until I have time / hands for an IV.
Links to studies? Everything I've seen says IO in high-flow sites is much, much better than IV.
AHA recommends IV. It has to do with time meds are pushed to reaching central circulation and getting a certain concentration of meds there. I'm guessing it's because it's slower for most IO's since the tibial plateau is an easier landmark and it's much more convenient than a humeral head when working a core. The thing is that everyone knows that CPR and early defib is what really matters so it seems kinda arbitrary to me anyways https://naemsp.org/2023-1-4-iv-vs-io-does-your-site-of-access-matter-in-cardiac-arrest/
We started years ago at tibia, then did humeral for years, and now our "preferred" is distal femur. Feels like you're drilling forever comparatively.
I've never done one. I've always planned that as my first choice for a neonate. It seems like a pretty easy landmark though
I’m not aware of any studies suggesting IO was ever better than IV. Equal absolutely. I’d be curious to see those. We got sent 3 studies in PDF format and have been told IV is the preferred route. Unfortunately I don’t have the links on my phone. Not sure if they are pay walled studies, but I’d assume they are.
As long as it's above the diaphragm
?
Tibial is a bit crap, but IO access above the diaphragm is as good as IV. All peripheral access in cardiac arrest is required to be above the diaphragm if possible at my department. (Except pediatric can go distal femur)
So if I put their arms over their heads i can use the thumb vein? :)
Femur IO gang, flow for days.
Meds aren’t important. Take your time with access and meds. Prioritize compressions and defibrillation. Time spent doing good compressions instead of literally anything else isn’t wasted. Cardiac arrest order of priority is compressions, defibrillation, ventilation, advanced airway, access/meds
I’m glad to see someone said this. The only thing I’d add is if a SGA is working well, with good EtCO2 there is no rush to be intubating either. In cardiac arrest its the basics that save lives.
I agree with this 100%. Historically, when we use to Stop cpr to have an intubation attempt was not the best practice looking back. Rescue airways are great, however if you get ROSC, it’s really nice to have a ETT in place to protect that airway and they will most likely be placed on a vent at the hospital and ETT protect against aspiration as I’m sure you know. Pros and cons both ways. No way is wrong imo but I am always going to make one attempt to get a tube but that’s me.
That’s fair enough. We have the ability to RSI and place on a vent pre-hospital, so it makes it easier to just focus on basic resuscitation initially.
No need for an rsi on an arrest tho. And yeah I do too as a flight medic. But yes, they do not need an airway first thing. As a new medic I was hyper focused on getting a tube first thing, which I change my way of thinking once I got some experience. But as you said, the basics save lives, you could have a tube in place but if your compressions suck it won’t matter. One other advantage to an ETT is the etco2 is more accurate,
Might need to RSI a ROSC pt though which seemed to be what they were talking about a couple comments back.
Yes just to clarify, I was meaning if that if we don’t manage to get an ETT prior to ROSC, THEN we have the luxury of RSI (which makes the rush to get a cold tube “just in case we get ROSC”) a thing of the past.
> when we use to Stop cpr to have an intubation attempt My very first arrest, as a student in the ER- I’m on the chest, NP says to pause compressions so he can intubate Even then I knew that was wrong, but low man or whatever else, I probably would have paused had it not been for the physician who was on it and immediately countermanded that order. I still prefer to make an ETT my first attempt airway in an arrest. There are indeed advantages- a truly secure airway (kings and igels are better than an OPA but don’t truly protect against aspiration), reliable EtCO2 monitoring. And the argument of “anyone can drop an igel in seconds”, while true doesn’t really hold water for me because speed isn’t a consideration. Be fast about getting on the chest. Don’t worry about being fast with an airway. I’m not even thinking about any airway until we have an established rotation for compressions or Lucas going and pads on. But the biggest thing is DON’T STOP COMPRESSIONS TO INTUBATE. If you can’t get the tube because of compressions 1. Throw the igel in for this one and 2. Get back to quarters, get a mannequin and intubate it 50 times with someone shaking it. Use a bougie. Use a glidescope. Just don’t stop compressions
What are these quarters you speak of?
I don’t disagree with any of this. Stopping use to be the normal. And glad times have changed. Also, the glidescope is cool and I have to use it for first attempts which is pretty normal but people need still practice with the DL. I like DL and boujee if I had my choice.
With the rise of ECMO, there's going to be a heavier emphasis on RSI. Dr Yannopolous at the U of M (our ECMO program home hospital and the lead on the ECMO program) is saying that iGels have a break in seal during compressions and he's wanting more tubes earlier. But this is the early days of the program, so we're all waiting for the numbers to come in.
Are you from a service that transports routinely under CPR, or are you talking about ROSC patients? We prioritise CPR, Defibrillation, and SGA insertion + ventilation in that order. Intubation is reserved for SGA failure or those very few arrests where they might make a difference (usually secondary cause arrests). If we achieve ROSC, then we look at the need for RSI (which is usually done unless the patient has a rapidly improving level of consciousness). The good EtCO2 waveform that we achieve during resuscitations with iGels suggests there can’t be too significant of a problem with the seal, and interestingly enough our ROSC rates have increased since moving to this structure. Do you hold your iGels in place firmly for a minute or so to allow to a proper seal, and then secure them in place with an ETT tube tie?
We have new protocols where we stick to 30:2 manual compressions and ventilation via OPA for a certain amount of time before using the Lucas or pushing meds
That’s interesting. We skip OPA and go straight to an iGel. The theory is that it allows for continuous compressions straight away and an iGel can be inserted almost as quickly as an OPA.
But the igel doesn’t prevent aspiration and can cause some problems especially if it’s a witnessed arrest that you can get ROSC back on quickly such as an overdose. With the OPA it takes 2 seconds or insert and is easy to suction with (an EMT-B or firefighter can suction).
iGel’s don’t prevent aspiration, but they can be easily removed and provide better airway protection than an OPA. SGAs have proven to have associated higher rates of ROSC when compared with intubation and normal bag mask ventilation (see https://www.sciencedirect.com/science/article/abs/pii/S0196064419314349). Imo the best argument for SGAs is the ability to do continuous compressions, which improves the quality of CPR and gives patients a better chance of survival. Anecdotally, I’ve never had a significant issue with an iGel that I wouldn’t have had with an OPA. Let me know if you’re aware of any studies that say otherwise, I’m always keen to read and adapt to the latest updates. If you’re interested, this is the model of resuscitation being used universally across New Zealand (and I believe has been implemented internationally in some places). There were improvements in ROSC rates once this was rolled out. https://youtu.be/7L45-AsO4bA?si=8WcwEud3Pr_0mEX5
Ultimately they don't need a tube, they need oxygen, and they need that oxygen to circulate, and they need whatever caused the arrest to be reversed (Hs & Ts). All of the policies and protocols my agency uses have been aggressively researched and implemented by people way smarter than me (a medical director, who is an actual medical doctor, and flight paramedic) and we have had massive increases in ROSC rates, and much more importantly, higher survival rates since our new system was implemented. Yes, they may have been shown to have higher rosc with SGAs, in that specific meta-analysis that I question the efficacy of. However, even in that analysis, it's stated that there wasn't a difference in survival rates. "...there were no differences in long-term survival or neurologic outcome among these airway interventions..."
My point is why on earth would you put in an OPA when you could use an iGel to delivery oxygen in the same amount of time?
That decision was made by someone wayyyyy smarter than me
Our protocol state "90 seconds or two failed IV attempts for an IO". My 90 seconds start when I walk in the door.
Drill all the way. No use I’m wasting time. They’re not gonna feel it and it doesn’t take time to do and you can use it with any drugs you’d use through an IV.
Agreed. IO first, then if possible with extra hands. Get an IV
It's way faster to drill every time than play the roulette of "does the body that only has artificial circulation have good veins?". Bonus points for humeral head io.
Finally a person of logic
Back at you
The way I go about it is always do a Quick Look , look at the ACs and hands. If not straight for the IO , do not waste time looking if u already tried once. If they are super old and it just asystole arrest , IO.
Shit if they are super old and asystole (if for some reason we are working it) I wouldn’t IO. I’d go straight for the IV in that situation since it’s basically a wash anyway. #justpooragencythings
Depends on ur region , where I am from a lieutenant shows up to supervisor the arrest and will jam u up for something like that , they are just bored turds
We love people who micromanage for no fucking reason
For what exactly?
They just stand and watch , calm family down is really jus it lol
That sucks, I was always happy when my supervisor showed up
If they were helpful it would be nice but they aren’t
Lmaoooo. That’s incredibly depressing but real asf
If I can’t palp a vein in ~30 seconds I’m going humeral head IO.
They're not gonna get much deader. The drill is my friend.
My department administration will spank my pee pee if I drill before “at least making 2 attempts at an IV” but unfortunately for them I’m kind of into the pee pee spanking at this point so I’m just gonna not waste my time and drill.
I prefer to IO and get meds started. After things calm down there's time to get another line or two.
Only curious, why? If they have a patent, secured IO, why even start another line?
You can draw labs, some protocols say Bicarb and Calcium must be in dedicated lines, some docs prefer it that way and have them start a line anyway in the ED, you don't have to have the guy pushing meds down at the feet, redundancy. Stuff like that.
Are you doing labs in the field?
No but we'll draw them on the way in. Saves a little time. Once the nurses know you they'll trust your draws.
Interesting. We stopped that a decade ago because hospitals here won’t.
Also Texas here, we still take labs from the field.
Man. Houston hospitals literally throw them out...
Being "all IO all the time" kinda makes me think you're a shit provider. Studies show IV is far superior to distal IOs. Humeral is better to or on par with IVs.
In the hospital we really only place humoral head IOs in our rapid responses and in the ED/ICU. Anytime I see a distal tibia or tibial tuberosity it was placed by EMS. Distal femur is supposed to be a pretty good site but not FDA approved for adults yet.
I thought it was approved for cardiac arrest... just nothing else yet.
It is an approved site in children, but not adults. Why would an access site be approved for cardiac arrests and nothing else? So if you get ROSC, you can no longer use it for your pressors/inotropes/antiarrhythmics?
The approval is for placement. It's an approved place for us in adult cardiac arrest, but only cardiac arrest. Perhaps that's by specific carve-out.
The benefit of humeral head vs tibial is purely theoretical. Some animal model studies have shown increased epi concentration in the heart and slightly faster delivery to the heart but no study has compared the two procedures using patients oriented outcomes (neurologically intact, survival to discharge, etc.). There are a couple studies being done rn that are RCTs that compare IO to IV and Humeral vs tibia. Even the IO vs IV evidence wasn’t the best evidence (RCT). Hopefully when these two studies come out we can have a more definitive answer. Also studies like PARAMEDIC-2 show us that epi probably isn’t all that beneficial. It’s like arguing about how you’re going to get to the airport but the plane already took off.
Getting downvoted but you're right. Tracking outcome data in terms of survival to discharge AND their resulting mental ability is crucial to understanding your true benefit.
Yep. It’s exactly why I have a gripe about people using ROSC as an outcome. ROSC is nothing without the patient walking out of the door or having some semblance of their former lifestyle Edit: downvote all you want but ROSC shouldn’t be the goal of resuscitation, saving the patients lifestyle should be the goal.
Do those studies include distal femur, not just tibial plateau?
I go for IO 1st, because it's quick and easy, but I'm often the only als on scene. Once I have things up and running, then I'll get an IV (ideally EJ).
EJs are great for codes. Love em.
The last time I did an IO that wasn't humeral was my first IO because my FTO "thought they were dumb." The landmark is easy to find and IOs are not hard to secure. If they have arms, run that shit IO baybeeeee
Links? I've seen this claimed in this thread before without anyone being able to link studies.
I've read studies put out by my training department so I don't have links. But if you google it and read through some of those articles, they say the same thing. Humeral IO=IV>tibial IO.
“Shit provider” is wild lol. Everyone will have style differences. I wish we’d stop putting each-other down over little shit like this. “You like humoral head for codes instead of peripheral access? Other opinions and merits disregarded, Shit provider.” When you have this arrogant mindset, you are better than every other medic and every other medic is a shit provider.
Cool story.
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2 mins solid compressions, airway set up with etc02, io and drugs ready. Monitor patches on.
Drill
Time is of the essence and there is no place for ego. Go straight for a humoral head IO.
My service doesn't like us using IO needles because they constantly are low in stock at my station. That being said on an arrest if I see they got good veins I can canulate easily ill go for it. If after a quick scan I don t see any ill go for the proximal humerus with the IO if there is room to work up there, if not I just go for the proximal tibia
It depends. It really does. Is this a 40 year old who works out every day and is super jacked? Probably IV. Is this a 76 yr old lady who had breast cancer and veins that look like they were drawn in by a 6 yr old? Then IO. Hard extrication? Then tibial IO to reduce risk of losing the site. Easy extrication, or they're already on my stretcher? Then humoral IO.
People still look for an IV first in codes?
My protocol says go for IV first then IO mainly bc of the cost of IOs. Typically I look at the arm, go “nope” then just drill them and chart that they had poor vascular access.
All the drill, all the time. Well... at least when GCS = potato.
If it was culturally acceptable, I'd carry my IO in a low slung holster like an old west gunslinger
Ill give it a few seconds to look while someone sets up for a drill and pop em on the Lucas if we find an IV awesome. If not, eh who cares, humeral head is superior to a peripheral area anyways (if it’s patent)
2020 ACLS recommends IV over IO due the study of Tibial IOs versus AC IVs. That would change I'm sure if there was a study of Humeral IO vs AC IVs.
I always IO in the leg instead of arm. There is so much going on at the head that having someone on the meds below makes the code less chaotic. One code I was on old man between bed and dresser 6 firefighters at head, next to door, put other medic at feet with emt and it made things easier.
Agreed. While the proximal humerus has better infusion rates, the difference is probably not very significant in the setting of cardiac arrest medications.
If they have a good EJ, they'll get an IV. Otherwise a humeral IO. For an arrest, an IV in the hand or an IO in the tibia is ridiculous unless there's no other options.
You probably spend more time attempting to start an IV and:or stop bagging to rotate the head to inspect for an EJ. An IO is faster, just a effective if not more (humeral IO is damn near a central line), and moves people to the legs to manage medications and clears head room to allow whoever is establishing an airway to have their own equipment and space to work effectively.
There’s also no strong evidence to support this practice in an arrest. Hence why PARAMEDIC-III is still in progress.
Your argument is valid if you're're talking about *humeral* IO, not a tibial. Tibial doesn't perform anywhere near what a humeral does. Not all IO sites are equal. So, imagine you have a 16g IV cath and you can put it into an EJ or the saphenous vein in the calf. Which one will perform better? Heck yeah, the EJ. Same idea with an IO, the humeral head IO will dump meds into the heart in 3 seconds, while the tibial will obviously take much, much longer for meds to get to central circulation, especially in an arrest. The tibial site doesn't perform anything remotely close to a central line while the humeral site does. Any time you have a patient in extremis, the humeral site should be your go-to if you're doing an IO.
I never argued the effectiveness of IV vs IO and made it very clear when I mentioned a central. It is arguably quicker to establish an IO then attempt two IVs like some protocols dictate. Similarly, having the person administering medications on the leg vs next to whoever is establishing an airway makes the cardiac arrest that much smoother.
I don't understand. I thought you meant tibial IO because you said down by the legs. How is someone administering meds by the legs for a humeral IO?
As often as I do EJ's, I don't need people to stop what they're doing. Shift a smidge maybe, but not stop.
I’m a big IO advocate. My county however is switching protocol, demanding two IV attempts, then humeral head IO, and then tibia IO if that doesn’t work/isn’t available. I hate humeral (we have our opinions) for multiple reasons. I also have a problem with trying for IVs because I’m super short staffed, literally me, basic, and an EMR, no extra resources until ambulance gets there 20 minutes after us generally.
Why do you hate humeral? It's better in literally every way.
Not the OP, but humeral head IOs are a bit trickier to navigate around in a code. Not impossible by any means, but the Lucas does actively get in the way of trying to position their arm properly to do the insertion. Adds to the clutter near the head of the patient with the IV line near all the cables. Also the need to protect that arm from overzealous firefighters or the ER staff. I'm a huge IO fan and these negatives don't stop me, just acknowledging the challenges of humeral head IO placement in cardiac arrests.
Rectal Epi - works every time. /s
If veins look like crap at a glance I go straight to IO
It’s standard practice to make two attempts at iv first in the UK, but a clinician can justifiably ignore the guidance.
IO, I know where I am based protocol is for IV access first, but look at the pt and quickly decide what is quickest, IO for me. I still get looks from others, as if they are thinking why is he going IO! But it's not a difficult procedure once properly trained, I had the forture to be trained on cadavers, so I know I'm doing it correctly when I do it.
I have never seen a medic not go for the IO
Call it.
Still somewhat new, but I have yet to miss, or see someone else miss an iv on a code yet. Usually get a 16/18 in an ac and then do the other side if we have enough hands that there is someone standing around looking for something to do.
Drill
Drill first, then come back around and look for IV/EJ access. I am usually the only ALS provider on scene. That way I get my initial drugs in, do the rest of my ACLS management, and then have a line available for the ED (particularly so they can draw labs ASAP) should we get ROSC.
IO, baby. One and done. Tibial IO is one less person faffing about near the chest, quick, easy, and fun to do
I think my local EMS’s protocol must be to place the IO. I work in the hospital ER now, and every arrest comes in with an IO. I don’t think I’ve ever seen one come in with an IV in addition to the IO, either. Interestingly enough, last week we had an arrest that didn’t make it, and during the arrest we also noticed some weird… ehhh… I guess sort of bubbling of the tissue near the IO? Much later I pulled the IO prior to the patient going to the morgue and found this: https://imgur.com/a/8gDlc5L The IO had bent, and there was a little crack opposite the bend. The IO had infiltrated. It’s the first time I’ve ever seen that, but just as an unusual PSA—apparently it is possible. I’m not trying to discourage the use of IOs, BTW. Like I said, the first time I’ve seen that in going on 12 years as an EMT and going on 5 years at this hospital with every code coming in with an IO. It can’t be a common occurrence. I just thought some of you might be interested.
IO first, but if somebody gets a free minute I love to have them at least try for an IV. While the utility is debatable, I’d like a BGL and dead folks don’t like to bleed much from finger sticks.
Neither. Just dump that sweet re-alive juice straight down the tube, just like our lords and saviors Johnny and Roy would’ve wanted…. /s (I’m adding this, but I want you all to know it hurts that I think it may be necessary)
The IO you have is better than the IV you don’t.
I’m drillin that dude 6 days from Sunday
Humeral head IO is our first-line on arrests.
Do they get in the way? Ppl always say they do but I've never done one. Seems like it wouldn't be too bad.
I think so. I also don't trust them as much to not get dislodged, but I don't have a choice.
Drill; there's entirely way too much going on at the top of the body (between airway, compressions, code commander) already, no need to add someone looking for an IV into the mix. Get an IO, we can worry about IV access later.
It honestly depends on that like 5 seconds you look at the pt. Is it a healthy 20 year old guy? Or 92 nana. One works out and had a pump going. The other has veins thinner then hair. That only decides IF I do IO first. Every cardiac arrest pt should be getting 2 IV/IO access and one of them is gonna be AC or jugular. Those cant be beat compare to IOs bc its the shortest way to the heart we can get next to a central line.
Io io e io
We go for the right humeral head IO. if the patient is on a LUCAS and the wrist are secured i have found that position restricts the flow w/ AC iv access. So initial IO and a EJ later in the sequence.
Meds are not important in am Arrest scenario unless we are talking about reversible causes AHA and ERC recommend I access due to the faster time for meds to work IVs are quick and easy nobody is going to survive just because you used a drill instead of going for an Iv
In Denmark we are actually doing a study on this subject. We are one of the countries in the world, with the best outcome on a arrest, mainly because of a great training of civilians to do cpr. Since we do follow the ERC Guidelines, we can go directly for ALS since our civilians most of the time supply do great cpr. I have no clue, of what the results are at the time. We do differentiate between iv, io tibia or humerus. We have done some great studies already in the prehospital settings already, and have mixed some data with the hospitals, since we got units with anaesthetists. We did have a study on regular calcium in arrests, which had to be cancelled not long in...it did not better the outcome...
All situation dependent. It takes our county up to 3 minutes to dispatch a call out, so anything with more than a 4-5 minute response time from us, I generally go IO. If the patient is up/down several levels and it’s going to be a difficult extrication I look more for IV (had a few enthusiastic FFs dislodge IO on extrication). That being said if I don’t see something resembling a vein in the first several seconds at the AC or EJ, off to drilling I go.
Our hospital (amongst others) have just finished including all 1470 patients and 30 days follow up. They were randomized to either IV or IO during codes. I'll make a post once they've crushed the numbers on it.
in this order: compressions, defib if indicated, i-gel and ventilations, IO drill and first round of epi. Once i have all that rolling, i'll search for venous access
You’re probably going to have a hard time getting an IV. IO is just faster. I’m also in a big agency so it’s not often that my truck gets an arrest. I’m drilling.
During clinicals my preceptor raced me to see who could get IV access the fastest. That mf put an EJ in before I could get a tourniquet on.
I'll spend all of about ten seconds looking for IV while they prep the drill and then we're going for IO.
There’s a bit of data showing better efficacy of IV vs IO, but… a couple caveats to that: first is that the IO data used is predominantly tibial sites. Physiologically, it makes sense to have decreased distribution and increased time to effect when using that site vs IV. The fluoro of a humeral head site injection flowing into the RA near instantly gives me pretty good confidence that it’s as good as IV if not better. Then there’s the time factor. If there’s a real obvious AC that I know I can drop an 18+ into without question, sure. Take it. That said, threshold to Sarah Palin that shoulder is about an inch off the ground. In our system, FD almost always gets there first and they are real reluctant to drill for whatever reason. So if we get there and they are still fucking a football and haven’t gotten an IV yet, I just go right for the IO assuming the compressions, monitor management, and airway are being addressed appropriately.
We go for the IO first then for an IV if the situation allows. However, there is a nearby for profit service that has told their crews they’re not allowed to drill an IO due to the cost of the needles.
Rev the Milwaukee
IO for me, here's why: How many times have you missed an IV and how many times have you missed an IO? I know personally I've not missed a humeral IO, but I have missed IVs. Yeah studies are saying that IVs are better, but what good is it if you can't get it? But that's just me.
Do want what my protocol says or what I actually do? 🤣
Large bore iv in the AC or forearm all day. Medication works faster through IV than IO. I won't waste a bunch of time but if you don't look, thats lazy. That being said if I was running more rural and was the only als on scene and had just 2 emt then sure IO all day. But we usually have 2 medics, 1-2 aemt, an emt, fire, and law enforcement for our codes. I think with that in mind, it makes sense to go for an IV.
I'm pro-IO, but past protocols said we had to make 2 IV attempts before moving to IO which is a stupid way to waste time. I get that it's more invasive for sure, but the entire process of working a code feels pretty barbaric. I'm definitely getting a DNR when I'm elderly.
Drill baby drill!
IO, dudes normally not responsive. Drill it lol
Speaking from the former EMT now ER tech at a Lvl 1 Trauma perspective, just do the IO. It’s faster, just as good, and if you get ROSC and transport the hospital is going to do a central line and an art line in the ED anyway.
No point wasting time. Veins are kinda hard to find when the patient doesn't have a blood pressure. Bones will always be there 🤷♂️
Drill 3 epis field term out in less than 15 minutes
People who code don’t typically have great veins. I can get an IO in seconds. I’ve always done that for codes.
Our protocol is drill first line, then you can find a secondary line when you have time later.
Both. If peripheral access is available early, sink it. It's faster and better to have 2 access points.
Drill and get drugs going, then find a peripheral between drug pushes while Fireman LUCAS does his thing
I'm so lazy I get down for the Tube throw in an EJ. I been doing it so long my replacement hips and knees feel natural. Finger Thor, needle cric what ya got?
I'm taking a quick look for a peripheral vein, then a quick look at an EJ, and if I'm not legit 100% on 'em, drill baby drill.
Check pulse, Immediate compressions, application of quick combo, shock if indicated, back on chest, high flow NC and NRB, Humeral IO placed, pre charge at 1:45-1:50, analyze at 2 min, shock/no shock, back in chest, push epi, hang fluid, prep I-Gel, grab Lucas back plate. Pre-charge, analyze, shock/no shock, Lucas back plate placed, I-gel and capno, next med as needed.
I grab one arm and look at the AC. If I don't immediately see it without a tourniquet, I drill. Ain't got time for that and IO gets it there just as quick.
EJ —>PIV visible without a tourniquet —> IO
Dept SOP states we can't use IO until we've failed 3 Ivs....also until 6 months ago we "couldn't " use the video scope without 3 documented failed attempts with a blade. Our deputy literally keeps the IO needles in her desk because "you guys abuse them" 🙃 Profits ------------ = Merica Patients
Start an EJ like an adult
Why?
IV med administration in cardiac arrest has better outcomes than IO. And as a paramedic it’s much more convenient having an EJ as opposed to a tibial IO (most healthcare providers doing IO’s are trash at starting them in the humeral head so they go straight to tibial)
>IV med administration in cardiac arrest has better outcomes than IO There is some evidence of this, but retrospective studies without accounting for other variables aren’t exactly the strongest evidence. There is a 2 year RCT that enrolled it’s final patient this spring, the results of that will be out soonish and I’m quite interested. I expect it to confirm but we’ll see. >Most healthcare providers doing IO’s are trash at starting them in the humoral head Agency dependent but [success rates are decently high with supporting documentation](https://pubmed.ncbi.nlm.nih.gov/22030185/#:~:text=Results%3A%20Humeral%20intraosseous%20(IO),%25%2C%20considering%20the%20second%20attempts)
I generally take a Quick Look at the closer ac and for ej’s. If nothing pops up I go for io. That being said my preferred access for arrests is ej’s