p roblem -b ased l earning 16 n ovember 2012 j ud m ehl, ca-3

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