External jugular

[Carlos Danger]

EJ's can be quite difficult in low-CO states, and many patients have a body habitus that makes accessing the EJ even more difficult.

With that in mind, I would probably never attempt an EJ if I had an IO readily available.

 

[medicsb]

Preference: EJ >>>> IO
However, ease of insertion: IO >>>> EJ

I personally found EJs easier to place in cardiac arrests. I still think of IOs as nothing but a temporizing measure, which can be fine i the short-term. Also, if you never attempt EJs, you'll never get good at them. I personally would prefer medics to either actually look for peripheral access (most seem to skip it altogether now), or place the IO and then once the time is available (obviously resource dependent) to find an actual IV site. I get the feeling that IOs have made many many medics lazy in their search/attempt at good venous access.

 

[Burritomedic1127]

Preference: EJ >>>> IO
However, ease of insertion: IO >>>> EJ

I personally found EJs easier to place in cardiac arrests. I still think of IOs as nothing but a temporizing measure, which can be fine i the short-term. Also, if you never attempt EJs, you'll never get good at them. I personally would prefer medics to either actually look for peripheral access (most seem to skip it altogether now), or place the IO and then once the time is available (obviously resource dependent) to find an actual IV site. I get the feeling that IOs have made many many medics lazy in their search/attempt at good venous access.

Personally don't feel IOs are making medics lazy, I think lazy medics are just that, lazy medics. Where I work , unfortunately, our medical control directors look down on EJs and encourage IOs. If the pt needs vascular access and peripheral attempts were unsuccessful or not attempted due to poor access we have to go straight to the IO. I don't believe that's makes me and my coworkers lazy medics. An IO is a perfect tool for a certain situation, why not have it available.

As far as IOs being a temporizing measure, what are tourniquets then? I don't work in a badass system that allows me to due surgeries in the back of the rig, so if I use a tourniquet am I lazy medic? IOs are access for us prehospital providers that allows us to help treat/stabilize/whatever the pt until we get them to the hospital where they have all sorts of meds/tools. Ultrasound guided IVs help.

Obviously there are people who would abuse IOs, but that's just who they are as a provider. And hopefully their CQI would start seeing trends and start asking questions. Peripheral access is better than IO access, yes, but in the right situations IO access is better than no access.

Oatmeal is better than no meal

 

[Carlos Danger]

Preference: EJ >>>> IO
However, ease of insertion: IO >>>> EJ

I personally found EJs easier to place in cardiac arrests. I still think of IOs as nothing but a temporizing measure, which can be fine i the short-term. Also, if you never attempt EJs, you'll never get good at them. I personally would prefer medics to either actually look for peripheral access (most seem to skip it altogether now), or place the IO and then once the time is available (obviously resource dependent) to find an actual IV site. I get the feeling that IOs have made many many medics lazy in their search/attempt at good venous access.

I'm all for spending time looking for better access once you get some access and other critical tasks complete. But IO's are reliable and I would bet on average, obtained much faster than IV's in shocky or arrested patients.

 

[medicsb]

Personally don't feel IOs are making medics lazy, I think lazy medics are just that, lazy medics. Where I work , unfortunately, our medical control directors look down on EJs and encourage IOs. If the pt needs vascular access and peripheral attempts were unsuccessful or not attempted due to poor access we have to go straight to the IO. I don't believe that's makes me and my coworkers lazy medics. An IO is a perfect tool for a certain situation, why not have it available.

I'm seeing medics often (almost always) negating attempts at IV access and going straight for IO. Sure, some (many?) systems encourage immediate IO, but nonetheless, in many of these patients an IV is obtainable. They were gotten in the days prior to IO. Sure, prior to IO there were patients for whom access could not be obtained thus the futile med admin via ETT (and those patients are perfect for IO). If you have an option to attempt an IV first, I'd actually recommend immediately looking at the EJs.

As far as IOs being a temporizing measure, what are tourniquets then? I don't work in a badass system that allows me to due surgeries in the back of the rig, so if I use a tourniquet am I lazy medic? IOs are access for us prehospital providers that allows us to help treat/stabilize/whatever the pt until we get them to the hospital where they have all sorts of meds/tools. Ultrasound guided IVs help.

Of course TQs are temporizing measures, but you do not need to immediately place a TQ on every patient with extremity bleeding (some gauze and direct pressure will work in most cases), just like you don't need to place an IO on every patient who needs vascular access.

Obviously there are people who would abuse IOs, but that's just who they are as a provider. And hopefully their CQI would start seeing trends and start asking questions. Peripheral access is better than IO access, yes, but in the right situations IO access is better than no access.

Oatmeal is better than no meal

I agree an IO is better than nothing and I have not said any different. But, what I am saying is that IO has also become a crutch for many, even providers who would otherwise not be considered lazy.

 

[Burritomedic1127]

I'm seeing medics often (almost always) negating attempts at IV access and going straight for IO. Sure, some (many?) systems encourage immediate IO, but nonetheless, in many of these patients an IV is obtainable. They were gotten in the days prior to IO. Sure, prior to IO there were patients for whom access could not be obtained thus the futile med admin via ETT (and those patients are perfect for IO). If you have an option to attempt an IV first, I'd actually recommend immediately looking at the EJs.



Of course TQs are temporizing measures, but you do not need to immediately place a TQ on every patient with extremity bleeding (some gauze and direct pressure will work in most cases), just like you don't need to place an IO on every patient who needs vascular access.



I agree an IO is better than nothing and I have not said any different. But, what I am saying is that IO has also become a crutch for many, even providers who would otherwise not be considered lazy.

 

[Burritomedic1127]

I know every system is different but I find that "almost always" medics are going straight to IOs when vascular access is potentially obtainable, hard to believe. Many places that I know of require at least X amount of IV attempts before going the IO route. If someone is doing IOs because of the hell of it, with probable vascular access available, then that's messed up.

But will gauze and direct pressure work on arterial bleeds? Or your single medic and your pt has 2 arterial bleeds should you still look down on the IO? No because these are certain situation where specific tools will make things easier for you the medic and your patient. I agree you don't need to place and IO on every pt who needs vascular access, I could only imagine all the emails/complaints you would receive for using IOs on line and ride jobs to the ER.

Your looking at IOs as if they are something negative. I understand your thought process of the "crutch" but I truly believe it's your perspective on them. Like I said its a perfect tool for a specific situation, that situation being your unable to obtain vascular access after trying for X IVs and the pt needs some emergent intervention/medication. I wouldn't want to be in the mindset of, I know I can hit the 24 ga in the pt's thumb on attempt number 4 so I can administered Dextrose to the unresponsive diabetic with no improvements from glucagon. In this scenario, it seems smarter and more beneficial to realize failed vascular attempts and move to IO access


My bad for double post, still working on replying and quoting threads

 

[medicsb]

I know every system is different but I find that "almost always" medics are going straight to IOs when vascular access is potentially obtainable, hard to believe. Many places that I know of require at least X amount of IV attempts before going the IO route. If someone is doing IOs because of the hell of it, with probable vascular access available, then that's messed up.

I should have been more clear, but I was referring to IO use in cardiac arrests.

But will gauze and direct pressure work on arterial bleeds? Or your single medic and your pt has 2 arterial bleeds should you still look down on the IO? No because these are certain situation where specific tools will make things easier for you the medic and your patient. I agree you don't need to place and IO on every pt who needs vascular access, I could only imagine all the emails/complaints you would receive for using IOs on line and ride jobs to the ER.

Depending on the arterial bleed, pressure and gauze may work just fine (done it before). 2 arterial bleeds... interesting "what if" scenario, but I don't see the need to jump to an IO except in the most dire of situations.

Your looking at IOs as if they are something negative. I understand your thought process of the "crutch" but I truly believe it's your perspective on them. Like I said its a perfect tool for a specific situation, that situation being your unable to obtain vascular access after trying for X IVs and the pt needs some emergent intervention/medication. I wouldn't want to be in the mindset of, I know I can hit the 24 ga in the pt's thumb on attempt number 4 so I can administered Dextrose to the unresponsive diabetic with no improvements from glucagon. In this scenario, it seems smarter and more beneficial to realize failed vascular attempts and move to IO access

I don't view them as a negative, but I do view their overuse as a negative. Again, EJs still work on hypoglycemic patients.

 

[Tigger]

Our supply guy/medic has us conditioned to at least take a look for an IV on arrests. We still drill plenty of people of course, but if a vein is around why not just stick them? I never understood the "immediate IO" on arrests. Drugs are not the priority and the extra fifteen seconds it takes to start a PIV are not a deal breaker. If I can't find something my partner will look at the EJ (off limits for me) before telling me to start an IO.

 

[Burritomedic1127]

I should have been more clear, but I was referring to IO use in cardiac arrests.



Depending on the arterial bleed, pressure and gauze may work just fine (done it before). 2 arterial bleeds... interesting "what if" scenario, but I don't see the need to jump to an IO except in the most dire of situations.



I don't view them as a negative, but I do view their overuse as a negative. Again, EJs still work on hypoglycemic patients.

Here's the most recent study I could find showing that IOs gain faster successful access compared to IVs in cardiac arrest: http://www.ncbi.nlm.nih.gov/pubmed/21856044. If someone has a garden hose for a AC that's in cardiac arrest, I say go for it. But if that's not the case, then get the IO to have access and look peripherally when/if you have time. Quick, easy, less complications, and frees up time if your solo medic. Granted the medications we push in ACLS are in question of actually doing anything helpful, but a quick IO and med administrations would be better than a multiple attempt IV with time lost. Got a kickass EJ doc but we only gave 2 epi's in 30 mins.

The IO and tourniquet were comparisons about the "temporary measure" you quoted earlier. I don't believe every patient needs a IO, only in the most dire of situations, I agree with you. But your pt that needs some sort of intervention, may or may not have EJ access available, whereas you have potentially 6 IO sites you could access. Unless they're some multiple amputee pt, then it's safe to say their bones will always be there.

Have to agree with Remi, low cardiac output could def flatten/make EJs disappear. Would rather know I can hit an IO quick to help intervene for sure than hope I potentially hit a spot where a vein use to be, potentially wasting time.

 

[emschick1985]

At least for a cardiac arrest in the field, always EJ. You can kneel at the head, turn it to the side, stick the EJ, straighten the head out, place your advanced airway, and voila, everything ALS is from the neck up. No worrying about compressors on either side getting caught up in your tubing and pulling your line.

This is why I like EJ's all at the head for everything

 

[emschick1985]

Here's the most recent study I could find showing that IOs gain faster successful access compared to IVs in cardiac arrest: http://www.ncbi.nlm.nih.gov/pubmed/21856044. If someone has a garden hose for a AC that's in cardiac arrest, I say go for it. But if that's not the case, then get the IO to have access and look peripherally when/if you have time. Quick, easy, less complications, and frees up time if your solo medic. Granted the medications we push in ACLS are in question of actually doing anything helpful, but a quick IO and med administrations would be better than a multiple attempt IV with time lost. Got a kickass EJ doc but we only gave 2 epi's in 30 mins.

The IO and tourniquet were comparisons about the "temporary measure" you quoted earlier. I don't believe every patient needs a IO, only in the most dire of situations, I agree with you. But your pt that needs some sort of intervention, may or may not have EJ access available, whereas you have potentially 6 IO sites you could access. Unless they're some multiple amputee pt, then it's safe to say their bones will always be there.

Have to agree with Remi, low cardiac output could def flatten/make EJs disappear. Would rather know I can hit an IO quick to help intervene for sure than hope I potentially hit a spot where a vein use to be, potentially wasting time.

Thankyou for finding the info!!!