Posted by: medicblog999 | October 22, 2009

Licence to Drill!

EZ_IO_G3Today, I had my clinical skills update which included the EZ-IO, intra osseous drill and cannula sets.

Its something that I know most, if not all, of my American colleagues have been using for quite some time. They all seem to rave about it and its uses, and I am really happy that I have this in my bag to use when the need arises.

The thing that will take the most getting used to, is deciding when to pull it out and use it and when to persevere with normal intravenous cannulation. Our guidelines for insertion are pretty vague, deliberately so, which leaves it pretty much up to clinical discretion and decision making for when it is appropriate to use.

We have the usual ‘when IV cannulation cannot be obtained’, but then we also have criteria such as ‘decreased LOC, patient in need of rapid fluid resuscitation’ etc etc.

The only absolute indication is for any cardiac arrest under the age of 6 yrs (which hopefully, I will not have to deal with)

But this all leaves me trying to decide when is appropriate to use it compared with IV.

If I have a patient who is obese and you know, just be looking that cannulation is going to be a nightmare, do I just go straight to I.O, or do I have a couple of attempts at I.V first?

If I have a cardiac arrest and I have had one go at a cannula and missed should I go to I.O then or should I try the jugular vein before I.O?

In an adult trauma patient who you would normally put 2 x large bore cannula in but you can only get one, would you put an I.O in as well?

I guess that all depends on the patient and their clinical need at the time.

Maybe I am thinking about this too much, but I like to run scenarios through my head and have an idea what I would do. Looking back on jobs, I am finding it difficult to think of more than a couple where I would have used an I.O, if I had them at the time. Maybe that’s because it wasn’t even a consideration at the time, but now I have them I want to use them appropriately, and for the benefit of my patients.

Do you use them as a last ditch attempt?

I know some of you have them as first line access for all cardiac arrests, that is not in our guidelines, but I can certainly see me putting one in for a ‘working’ resus, if I haven’t got my cannula first time round.

I would also like to hear about your experiences of putting them in to conscious patients, and how they responded to the insertion and also when you told them what you are planning to do.

“OK Sir, I am just going to pop a little needle into your arm” sounds far less stressful then “OK sir, Im just going to drill a needle into your bone” !!

I know I will say it a bit kinder than that, but you get my point.

Please leave a comment and let me know of your experiences. In the mean time, here’s a little video for you to watch of some doctors practising inserting the EZ-IO on each other!!!:

[pro-player width=’530′ height=’253′ type=’video’ image=’http://www.youtube.com/watch?v=uU7l6y92kgo&feature=youtube_gdata http://www.youtube.com/watch?v=uU7l6y92kgo&feature=youtube_gdata http://www.youtube.com/watch?v=uU7l6y92kgo&feature=youtube_gdata’%5Dhttp://www.youtube.com/watch?v=uU7l6y92kgo&feature=youtube_gdata [/pro-player]

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Responses

  1. Wow!! What a video! No-one is ever going near me with one of those when I am awake!!! Seriously, there is no doubt that these babies are invaluable in the pre-hospital arena. I personally don't have one, but need one badly. I would suggest that they are used when you need access quickly annd you an't get it – when you are struggling to get iv access and the patient looks like you don't have any more time. I had just one such scenario a few weeks ago, and would have loved to have drilled her leg…

  2. Our local paramedics have the “bone gun” that shoots a catheter into the IO space. Is the EZ-IO better than that?

  3. Jesus the medic who is being drilled is so carm. It looks so painfull tho I can imagine it ill be usefull to you lot.

  4. The painful part is not the drilling, it's infusing fluids or medications. That is likely the pressure, but might be related to the colder than human body temperature of the fluids or medications. We can give Lidocaine after starting the IO, but before we give anything else. The EZ IO is much better than the bone injection gun, at least from what I've seen. I finally got to use an EZ IO this morning, it's actually pretty easy.

  5. I am not a paramedic so I have no training or experience with the EZ-IO, but I have seen my paramedic partners use it before. A few things I noticed:1) During a cardiac arrest, an experienced paramedic was able to get a peripheral IV before the less experienced medic got the IO kit out and prepped. This is not the case every time, but I would have to say that making the IO the default access route for any call isn't appropriate.2) Whenever someone was unable to establish a peripheral IV due to obesity, the IO needle was too short to stay secured to the patient. More often than not, it popped out or never drilled deep enough.Just things to consider.

  6. I recently had 42 IV therapy treatments. The nurses often had a hard time putting in the IV line and once in, it wouldn't stay more than a day or two (if I was lucky). This was not only because I am overweight, but I have never had good veins, even when I was thinner. Often, they couldn't even feel the veins. Why they didn't put in a PICC line is beyond me. As it turned out, I didn't even really need the treatment I was being given, so I had 42+ “pokes” for nothing. But if I saw someone coming toward me with a drill, I would have run!

  7. I can't help but feel that if you're saying “OK Sir, I'm just going to…” they're probably way before the stage you'll be needing to resort to IO access? 🙂

  8. Hi Mark,I dont know which is better as I have never seen the 'bone gun' in action. EZ-IO seems to be the one which has the greatest uptake from the Ambulance Services, but if it is better or not, I dont know.Anyone else know or have an opinion?

  9. Hi TOTWTYTR,The powers that be were going to give us lidocaine to infuse prior to fluids etc, but it was decided that we are not getting it!What patient presentation did you use it on this morning (if you can say!)?

  10. Hi Ben,I too had the thought about the obese patients, but assumed that even the biggest patient doesnt have a huge amount of fat and tissue sitting above their tibial tuberosity so just assumed that the needle would reach the right spot. Maybe not then??

  11. Nick,I cant think of many occassions when I would be saying that either. Maybe in the critical anapylaxis patient when you just cant get access, or in the shutdown, septic, hypotensive patient?There may well be cases where it becomes apparent that it is needed, however, I dont want to be the guy you uses it when I could 'manage' with other means. However, when those other means are exhausted, then at least we have something else to use now.

  12. I'm sure your commenters will cover the 'unconscious' uses well enough. I'll just say I love my EZ-IO gun. For the really obese patients, they've recently introduced an extra long needle, although I haven't had the chance to use it yet.As I mentioned over at Ckemtp's place, it has become my personal first line option in cardiac arrests. (I understand the comment about the time factor, but I believe that's more to inexperience than anything.) Properly deployed, it's FAST.I have had one occasion to use it on a conscious patient, and on the humeral head. Pt was severely hypothermic with frostbite and peripheral constriction. Chances of an IV succeeding were slim. Patient simply looked at me and calmly said “Oww.” I think he might have reacted worse if he were more stable, but if so he wouldn't have needed the IO.

  13. Our patient was in cardiac arrest, so pain wasn't an issue. We didn't have Lidocaine at first, but there were so many complaints from the medics, that they changed the protocol. For any conscious, or even unconscious patient, the Lidocaine is important.

  14. Yep! This device is pretty cool and exceptionally easy to use. The EZ-IO company must have had some great engineers working for them, because this make IO access so much less difficult, especially when compared to the other IO access devices I've used or seen. I've personally put in about 20 in the past year.A few guidelines I use in deciding to reach for this particular part of my bag:(1) I would need a very very very good reason to reach for it in a conscious adult patient. In fact, with the exception of perhaps a patient in unstable VTach with no venous access, I doubt I would ever submit a conscious patient to this particular torture. Though, and I can't remember if this was part of my inservice or not, I've heard that a bit of lidocaine through the IO after access in a conscious patient goes a long way.(2) Cardiac Arrest: Now I usually do a check for IV access, but unless there are very prominent EJs, my next step is usually the IO.(3) Trauma Patients: While they say that a bag under pressure through an IO can deliver the same amount of fluid as a large-bore IV, I don't believe that's true. There's nothing like bilateral 14ga's for the quickest method of turning your patient's blood into Kool-Aid! Even one good IV is much better than the IO for trauma, and actually I would prefer to spend some extra time with an external jugular cannulation than IO a trauma. In short, really a “definitely better than nothing” route in trauma.(4) You'll find that establishing an IO in grossly obese or edematous patient is almost equally or more difficult than IV access. This is because the needle cannot physically reach and then penetrate the bone after going all the way through the soft tissue. My service has not yet starting stocking the “extra-long” IO needles for these patients that were just recently released, so I'm not sure if IO access is any easier with the “yellow-top” needle. The company rep who spoke to my company suggested that it should take care of most of the problems.

  15. Where I work the pt must be unresponsive and you must have tried 2 attmepts at IV canulation before you use an IO, including trying to get a jugular vein. This rule even applies with diabetics. We do Diabetic scene treats and if necessary we can IO them and they still have the right to refuse to go to the ER. So we end up removing and bandaging the area for them afterwards.

  16. The bone gun is insane. We got to test both products out and the EZ IO is so much better and smoother.

  17. Did you have to practice using it on one another as well when being trained? It seems like a very handy piece of equipment in the right situation! Though if anyone came at me with one while I was conscious, I'd start running.

  18. It's a wonderful tool, but I'd rather use the old-fashioned manual IO needle in the very young. Putting an EZ IO in a six week old baby is very easy to drill all the way through the bone, which I have actually done. There's just no sense of “touch” when you use the EZ IO – no pop, no sudden lack of resistance, nothing. In an adult, the EZ IO is easier, but when I put an IO in an infant, I depend on tactile sensation to tell me when I've entered the marrow cavity.

  19. Looks like I'm late to the party. If you're an experienced provider who can draw on instinct, you'll be fine. I use it for “I HAVE to have an IV NOW” patients where I don't think that I'm going to get one otherwise. If the patient is conscious, I try to go with a regular IV access. In fact, I haven't had to put one in a conscious patient yet. I can see the benefit, which is already well stated here, but I know that you'll be fine.

  20. 1) It's not a contest. If venous access is available, then that's the preferred route. It's when you can't find a vein that you should use the EZ IO. 2) They make extra length IO needles for that occurrence. They are fairly new (about 1 year) so some systems don't have them I'm sure.

  21. IO drills are awesome. As far as when to use them, if your protocol is as non-specific as mine, then it's just your discretion. If you have an arrest on someone you know you won't find an IV in (mostly IV drug users), I think it's completely appropriate to start with the IO. But the good point was raised, that due to experience, sometimes it takes longer to set up the IO. Unrelated to IO drills, I sent you an email about Trauma.

  22. Actually RRD, it doesn't hurt bad at all. I let them demonstrate it on me, and honestly, the insertion was far less painful than the 18 gauge IV in the back of my hand during a bout with kidney stones a few years back.Now, when they push the fluids in under pressure… that hurts bad enough that they'll have to roll you over and pull the sheets out of your behind afterward.

  23. EZ IO, Bone Injection Gun, and Fast1 sternal IO access are all pretty user-friendly, but in my opinion the EZ IO is by far the easiest to use. The BIG has been used successfully in Israel for quite a few years now.

  24. Comparing apples and oranges, Ben. Compare two equally experienced medics with IV cannulation and the EZ IO, and the Io is a good deal faster, and it's damned hard to miss.

  25. Comparing apples and oranges, Ben. Compare two equally experienced medics with IV cannulation and the EZ IO, and the Io is a good deal faster, and it's damned hard to miss.

  26. Not only do they have longer needles for obese patients now, but you can also try the distal tibia site – 1 finger's width above the medial malleolus. It works well on obese patients, unless they have cankles.

  27. Not only do they have longer needles for obese patients now, but you can also try the distal tibia site – 1 finger's width above the medial malleolus. It works well on obese patients, unless they have cankles.

  28. Fair enough – I respect your comments, but I will say again – no way is anyone doing that to me while I have the conscious level to stop them!! I had a play with one at the Basics 2009 Conference today, and I'm getting one!!

  29. I have used the both Bone Injection Gun and the E-Z-IO drill. I prefer the drill. Just from basic physics it seems that the drill does less damage and there is a film out that shows this using an egg as an example. I have also had much better success with the drill than the gun.

  30. MarkAs you can see in the protocol that I sent you, Lidocaine is givien for pain with infusing, You might want to try and start one on management and see how much they enjoy it without the Lido, and Lido is relatively cheap.

  31. I have used the both Bone Injection Gun and the E-Z-IO drill. I prefer the drill. Just from basic physics it seems that the drill does less damage and there is a film out that shows this using an egg as an example. I have also had much better success with the drill than the gun.

  32. MarkAs you can see in the protocol that I sent you, Lidocaine is givien for pain with infusing, You might want to try and start one on management and see how much they enjoy it without the Lido, and Lido is relatively cheap.

  33. Hi all.this driller looks nice.I'm an Israeli paramedic and we use exclusivly the Bone injection gun. i don't know if some of you know it.we have a lot of expiriance in MCI and therefore even after reading this article i think we will continue using exlusively B.I.G. it is automatic and there is no need of baterries. plus i think its alot cheaper.have you ever seen that B.I.G?Jonmedic

  34. Hi all.this driller looks nice.I'm an Israeli paramedic and we use exclusivly the Bone injection gun. i don't know if some of you know it.we have a lot of expiriance in MCI and therefore even after reading this article i think we will continue using exlusively B.I.G. it is automatic and there is no need of baterries. plus i think its alot cheaper.have you ever seen that B.I.G?Jonmedic

  35. Hi all.this driller looks nice.I'm an Israeli paramedic and we use exclusivly the Bone injection gun. i don't know if some of you know it.we have a lot of expiriance in MCI and therefore even after reading this article i think we will continue using exlusively B.I.G. it is automatic and there is no need of baterries. plus i think its alot cheaper.have you ever seen that B.I.G?Jonmedic

  36. Hi all.this driller looks nice.I'm an Israeli paramedic and we use exclusivly the Bone injection gun. i don't know if some of you know it.we have a lot of expiriance in MCI and therefore even after reading this article i think we will continue using exlusively B.I.G. it is automatic and there is no need of baterries. plus i think its alot cheaper.have you ever seen that B.I.G?Jonmedic

  37. hey fellows, thought you should see this one: http://patrickandpatty.blogspot.com/…ome-agai… As a paramedic using a differnt device for IO, i think this important for use caregivers to know that. Jonmedic

  38. hey fellows, thought you should see this one: http://patrickandpatty.blogspot.com/…ome-agai… As a paramedic using a differnt device for IO, i think this important for use caregivers to know that. Jonmedic


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