P ROBLEM -B ASED L EARNING 16 N OVEMBER 2012 J UD M EHL, CA-3

C ASE 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.

A SSESSMENTS : 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.

W HAT DOES THIS PATIENT NEED R IGHT NOW ? Respiratory Support Vascular Access Hemodynamic Support And then she codes...

S O 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??

S HOULD WE PUT THE DRUGS DOWN THE ETT?

V OTE 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

L ETS 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.

T HE PAST : IO was primarily reserved for critically ill children. It was never thoroughly studied as a treatment in adults. However this is currently changing

T HE BASICS OF THE IO

B UT WHO WOULD DO THE STUDIES IN ADULTS ? W HAT 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.

B EFORE WE JUMP INTO THE RESEARCH, LET ME SHOW YOU ONE MORE THING For the non-believers: EZIO infusion Its pretty impressive !!

S O 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

B UT, 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.

T IMELINE 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.

S O 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 hours 40 patients Ages Trauma in 29 of the cases

DATA:

O THER IN-HOSPITAL STUDIES

D RUG D ISTRIBUTION

R ESULTS

C ASE REPORTS

B UT 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.

I N 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

S O HOW DO YOU INSERT THE THING ? Where? Lateral Humeral head Proximal Tibia Distal Tibia We know that the flow rates differ between these sites player_detailpage&v=PL3DMY1Zln0#t= 581s

S O, START TO FINISH : 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 !!

N OW WE NEED A VOLUNTEER... To try it on the mannequin