PROBLEM-BASED LEARNING16 NOVEMBER 2012JUD MEHL, CA-3
CASE 68 yo female patient from local “nursing
home” DM II HTN CVA Stage 2 sacral ulcers
Per NH staff, patient has been “breathing heavy” and tired most of the day. Her BP was also a little low and they thought they should send her in to the hospital.
ASSESSMENTS: Very warm Nearly obtunded Thready pulses Labs drawn, but
unable to get an IV
ER staff and you in house. He calls you for intubation and line placement. He has tried 3 times at both.
WHAT DOES THIS PATIENT NEED RIGHT NOW? Respiratory Support Vascular Access Hemodynamic SupportAnd then she codes . . .
SO NOW WHAT? What are our options for venous access?
What are our options for medication administration?
What are we going to do if we actually get her back and need pressors??
SHOULD WE PUT THE DRUGS DOWN THE ETT?
VOTE TIME How do you handle this case right now?
A. Drugs down the ETT B. Blind stick for a central line C. Ultrasound for a central line D. Intracardiac injection E. Intraosseous line
LETS CHAT ABOUT THIS IO THING Would you :
A. Feel completely comfortable placing an IO and knowing what can be administered through it
B. Feel OK placing it, but have no idea what I can give in it
C. I could figure it out, I think. Maybe point it to a bone and start pushing?
D. Would never even think about placing one.
THE PAST: IO was primarily
reserved for critically ill children.
It was never thoroughly studied as a treatment in adults.
However this is currently changing
THE BASICS OF THE IO
BUT WHO WOULD DO THE STUDIES IN ADULTS? WHAT IRB WOULD APPROVE, AND WHO WOULD CONSENT? Solution: you introduce the device to a place where
consent is frequently implied, and you study it there:
But more on that in a minute
IO IN EMS The pediatric IO has been a part of the
pediatric emergency kit for many years
Adult IO has emerged into EMS within the last 10 years as a second-line access device, though many systems now use these as first-line access on out of hospital cardiac arrest, both medical and traumatic.
BEFORE WE JUMP INTO THE RESEARCH, LET ME SHOW YOU ONE MORE THING For the non-believers:
EZIO infusion
Its pretty impressive !!
SO WHY IS THIS IMPORTANT These devices will be critical backup for
vascular access in the difficult patient They are rapidly becoming first-line
treatment for patients in cardiac arrest without pre-existing access, both pre-hospital and in-hospital
They are easy to place with high success rates
You are very likely to start seeing these devices show up in the OR on emergency cases as they are proving themselves to be both safe and effective in the adult population
BUT, THE RESEARCH IS STILL IN ITS INFANCY There are multiple access sites
Tibial, Humeral, Sternal – which is best? Sternal site proved to be a problem during CPR
Complications appear to be minimal, though again the research is still ongoing.
A TIMELINE OF THE IO 1920’s – Drinker et al. demonstrate fluid
administration into the marrow cavity reaches central circulation
1934 – First reported use of IO access in human
1940’s – IO comes into favor in treating pediatrics
1950’s – Plastic IV catheter comes on the market
1980’s – First PALS curriculum reintroduces IO access for pediatric patients after failed attempt at vascular access. Endorsed by AHA, ACEP, AAP.
TIMELINE 1993 – PALS update says go to IO after 3
failed peripheral attempts 2005 – AHA liberalizes their stance: “If you
cannot achieve reliable IV access quickly, establish IO access.”
2005 – AHA guidelines revised to include recommending IO access in adults with cardiac arrest when IV access is not immediately available.
SO IT’S A COOL GADGET FOR PARAMEDICS . . .
BUT . . .THEY ARE SLOWLY CREEPING THEIR WAY INTO THE HOSPITAL AS WELL
Prospective Observational study
N=40 Critically ill patients requiring
resuscitation at level I trauma center without at least 1 effective 18-gauge after 3 attempts or 2 minutes
Exclusion: under 18 yo, pregnant, prisoners
All patients meeting criteria got both a CVC and IO placed via standardized protocol by two experienced independent operators. Anesthesiologist – landmark
CVC Surgeon - IO
OUTCOME MEASURES Success rate on first attempt Time to completed insertion from opening kit to
infusion of meds/fluids
Secondary outcome measures: Complication rate
Failure, malposition, dislodgement, bleeding, compartment syndrome, arterial puncture, hemothorax, pneumothorax, infection
All IO needles were cultured following removal at 24 hours40 patientsAges 18-87Trauma in 29 of the cases
DATA:
OTHER IN-HOSPITAL STUDIES
DRUG DISTRIBUTION
RESULTS
CASE REPORTS
CASE REPORTS
BUT THERE ARE STILL HUGE HOLES IN THE DATA . . . Further studies on complications Further research on outcomes
Does the fact that we get faster vascular access actually lead to patient survival?
Resuscitation is a hard thing to study. Much of our current data is from animal models.
IN FACT: There are
sporadic case reports about pediatric osteomyelitis.
Other case reports include rare instances of tibial fracture or compartment syndrome
62 yo male, known DM, MGUS
SO HOW DO YOU INSERT THE THING? Where?
Lateral Humeral head
Proximal Tibia Distal Tibia
We know that the flow rates differ between these sites http://www.youtube.com/watch?featur
e=player_detailpage&v=PL3DMY1Zln0#t=581s
SO, START TO FINISH:
http://www.youtube.com/watch?feature=player_detailpage&v=3pZxOqfB3YA
A COUPLE HINTS Stabilize the extremity
Flush the marrow cavity with 2% lido immediately after insertion in the awake patient
Secure it well – the most common complication is dislodgement
Don’t be AFRAID of this device . . . it will have a predominant role in the future of ACLS in patients without pre-existing access !!
NOW WE NEED A VOLUNTEER . . . To try it on the mannequin
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