Versed IN verses IM

[mike1390]

IO for a seizure? brutal....

 

[NomadicMedic]

IO for a seizure? brutal....

Seriously? Status seizures get drilled. No question.

 

[Carlos Danger]

Seriously? Status seizures get drilled. No question.

I know. I'm pretty surprised at the squeamishness about IO's among the folks here. If you wouldn't place an IO for a seizure, when would you place one?

I've placed dozens of them for seizures, RSI's, traumas, everything. Seizures are actually a perfect, textbook indication for an IO.

Put it in, push the meds, and when you eventually get an IV you can pull it out and put a bandaid over the small wound. No big deal.

 

[joshrunkle35]

I notice no one prefers the rectal route

 

[chaz90]

I know. I'm pretty surprised at the squeamishness about IO's among the folks here. If you wouldn't place an IO for a seizure, when would you place one?

I've placed dozens of them for seizures, RSI's, traumas, everything. Seizures are actually a perfect, textbook indication for an IO.

Put it in, push the meds, and when you eventually get an IV you can pull it out and put a bandaid over the small wound. No big deal.

I'm not squeamish about IO placement. They have their place, and are an absolutely essential tool as far as I am concerned. My question about placing them in seizure patients was only in reference to not preferring them over IM or IN Versed. If IM Versed stops active seizures ~80% of the time, why not stop the seizure then grab a quick IV?

If I have a status seizure patient refractory to IM Versed, I would have no problem drilling them for additional dosing.

 

[Carlos Danger]

I'm not squeamish about IO placement. They have their place, and are an absolutely essential tool as far as I am concerned. My question about placing them in seizure patients was only in reference to not preferring them over IM or IN Versed. If IM Versed stops active seizures ~80% of the time, why not stop the seizure then grab a quick IV?

If I have a status seizure patient refractory to IM Versed, I would have no problem drilling them for additional dosing.

I don't doubt that IM works most of the time, but it's the slowest and most variable of all the routes of administration.

The potential problem with the strategy of giving IM and then switching to IO if needed, is that with 10-15 min to onset via the IM route, you are potentially looking at waiting 15 minutes before you know whether you have to re-dose. That's a long time if the patient has already been seizing a while.

IN might be a good option, but it seems like the jury is still undecided. IV is clearly the gold standard if you can get one quickly, and distribution and onset of IO is very similar to IV.

I think of all the options, IM really should be the last resort.

 

[chaz90]

The RAMPART study seems to indicate that IM Versed is far faster than 15 minutes and has a high efficacy. I'm not saying that's the end all study by any means, but it's certainly some good evidence.

 

[Carlos Danger]

The RAMPART study seems to indicate that IM Versed is far faster than 15 minutes and has a high efficacy. I'm not saying that's the end all study by any means, but it's certainly some good evidence.

Just looked at that quickly. I've heard of it before but never read it before now.

I'm not sure why anyone would even want to study IM midazolam vs. IV lorazapam? Kind of comparing apples & oranges, in that midazolam is well known to have a faster onset than lorazapam.

You are right about the onset in that study, it was extremely fast.....almost suspiciously fast....as in, IV midazolam isn't even that fast sometimes.....

I'll look at it more closely tomorrow.

 

[Handsome Robb]

I know. I'm pretty surprised at the squeamishness about IO's among the folks here. If you wouldn't place an IO for a seizure, when would you place one?

I've placed dozens of them for seizures, RSI's, traumas, everything. Seizures are actually a perfect, textbook indication for an IO.

Put it in, push the meds, and when you eventually get an IV you can pull it out and put a bandaid over the small wound. No big deal.

I wouldn't call it squeamish. I agree that in a status seizure patient and IO is absolutely indicated and probably safer, in all honestly, for the patient and provider than an IV. Firefighter holds the leg, find your landmark, clean it real quick then drill it and you're done, don't have to worry about holding tamponade then securing it.

I've drilled two successful live IOs and two unsuccessful ones, both because of lack of a bariatric needle which still puzzles me to this day why we don't carry them. One successful one was a trauma patient that arrested shortly thereafter however did regain ROSC and maintain it until surgery, the other was an acute liver failure patient with a massive lower GIB that coded later that day in the ICU.

There's a time and a place for IOs, I just don't think the majority of seizures are that place. I may be misinformed but I was under the impression placement of an IO guarantees a long road of IV antibiotics afterwords, we are not permitted to disconnect them.

Per protocol we can go to an IO afte two peripheral attempts or can humor to it on the medic's discretion with a good reason as to why.

 

[Carlos Danger]

I may be misinformed but I was under the impression placement of an IO guarantees a long road of IV antibiotics afterwords,

Yeah, you were given some bad info there.....IO's require no post-treatment whatsoever. It is exactly the same as DC'ing an IV.

The other big advantage to an IO vs. IM is that once it's placed....you have vascular access. If you have a seizing patient and you give midazolam, and it doesn't work and the seizure continues and the patient decompensates, you already have a route in place for resuscitation meds and fluids. You can push RSI meds, epi, anything that you can give IV.

I was the educator at a HEMS program that served as one of the market test sites for the EZ-IO. We did a lot of education on IO's in general and the Vidacare device specifically, and used the device A LOT during the several month trial period and after. We had great results with it, and my program's experience was the basis for much of the research that was used to help market the device. My medical director at the time had always felt like IO was an under-utilized route of medication administration, and that the main limiting factor was lack of a good device for placement (the FAST1 sucked). My experience with them there taught me how useful they are and convinced me, too, that they are underutilized in both EMS and the hospital.

That was back in 2003, and since then there's been a pretty substantial body of research done on IO's, and it generally shows that IO's are faster to place and least as reliable as PIV's, and result in the same or fewer rates of complications. That's why when I hear about people fiddling around with IN and IM meds and CVC's during crisis situations, I kind of cringe and the first thing I ask is "did you consider using an IO"?

The primary deterrent to greater acceptance of IO placement seems to be the perception that it is exceedingly painful.....and that really isn't true, either. The one study that I know of (unfortunately was not published, I don't think) that looked at pain showed that patients thought that IO placement was less painful than a large-bore IV placement. And that's about in line with my experience. Infusion can be quite painful, but if you are just using for meds, it only takes a few seconds to push and flush. 2% lido helps some people a lot, and fentanyl does too.

 

[Dwindlin]

I'm going IN everyday of the week before I attempt any kind of invasive access.

 

[DPM]

In my county we can go IV/ IM/ IN Midazolam for Seizure.

I had a 5 month old seizing the other day. Weight 5kg per Braslow tape so she was going to get 0.5mg IV/IO/IM or 1mg IN. As I normally do, I drew up the entire 5mg / 1cc of versed, popped on the atomizer and then 0.1cc up each nair. Shortly after the baby started "drooling" for a better word. Still seizing, suctioned the mouth. A few mins later the seizure broke. Baby's now awake and crying, Sat is still good, it looks good.

My questions are this:

Safely administering 0.1cc at a time was tough. This meant I had to do it slowly, which is the concern. Our protocols say to administer it briskly, which I couldn't really do, and I was concerned that some of the "drool" was the midazolam leaking into her mouth. Any one had this problem? One solution I've thought up is to only draw up the initial dose, so I don't have to worry about giving too much. Any one got any other ideas?

I'm liking IO, I didn't think about it at the time and I will in future. We didn't manage access prior to ER arrival, but we luckily we didn't need it. I'm hesitant to go IM. Thoughts?

 

[Angel]

hmm, will an atomizer fit on a 1cc syringe (never tried it)...i highly doubt it couldve been versed leaking from her mouth but anythings possible i suppose. IO seems like over kill for this patient, especially because you can always give it IM.
it would be a lot easier (especially not to accidently give too much) to just pull out the amount you need and give it that way. then to waste just get a new syringe.

did you try an IV or just straight to IN? Ive gotten 22G on 1 year olds so it is possible.

 

[DPM]

Went straight to IN. And yeah, in future I'll only be drawing up what I need. The MAD fits on the little 1cc syringe, its the same size as everything else.

The IV is definitely possible, I had a good look but didn't find anything in the time I had. In my experience going straight for IN works well, I just had that issue in this case.

 

[RocketMedic]

I agree the IO is safe and effective, but sadly, most of us still live in the QI dark ages. Drilling a nonarrested patient is deeply frowned upon by paleolithic sorts.

 

[Angel]

Drilling a patient you could easily get an IV or give the med IM/IN just doesn't make sense to me, QI aside, least invasive to most invasive just seems better for the patient.

 

[RocketMedic]

Depends on the ease of access. I've honestly never really had a problem with starting an IV if I've got the hands and they've got the veins.

 

[EMT11KDL]

hmm, will an atomizer fit on a 1cc syringe (never tried it)...i highly doubt it couldve been versed leaking from her mouth but anythings possible i suppose. IO seems like over kill for this patient, especially because you can always give it IM.
it would be a lot easier (especially not to accidently give too much) to just pull out the amount you need and give it that way. then to waste just get a new syringe.

did you try an IV or just straight to IN? Ive gotten 22G on 1 year olds so it is possible.

The atomizer will fit on any syringe, it twist in just like a normal needle does.

 

[DesertMedic66]

I'll take a look for IV access, if I can't find anything fairly quickly then I'll go to IN/IM. I'm not going to drill an average seizure patient.

 

[EMT11KDL]

I'll take a look for IV access, if I can't find anything fairly quickly then I'll go to IN/IM. I'm not going to drill an average seizure patient.

Usually I can get something in the hand Or wrist, if not IN