# Medical. : EV IO's bilateral if patient if patient is in shock/trauma



## 8'Duece (Jan 13, 2010)

Would it be contraindicated to use two  EZ IO's , bilaterally on both proximal tibs if the patient needs more fluid than is being infused by the first IO ?? 

Say, you need an IV but patient is suffering blood loss, external, internal and you need to increae fluids but no vasuclarity is yet present. 

Does that make sense ???


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## 8'Duece (Jan 13, 2010)

I meant "EZ IO" in the title.  Sorry.


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## HoosierAnnie (Jan 13, 2010)

My question would be oif the patients vascularity is THAT frigging compromised, how in hades are their tissues getting O2???


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## 8'Duece (Jan 13, 2010)

let's say low O2 sats, comprimised airway ??  nuemo from GSW, something like that, prior IV drug user ?


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## HeloMedic1171 (Jan 14, 2010)

I'm probably not qualified/certified to answer this question, but my *opinion* is that if it saves the patient's ife, and saving their life is your end goal, then try it.  We use F.A.S.T. 1's, so bilateral isn't an option.  what are you trying to do, push drugs like, "time: now" or jut get fluids in ASAFP?  if it's drugs you're after, it *may* be in our (and their) best interests to take your chances with I.M. drugs and I.O. fluids than to do bilat IO sites.  but then again, if it works, then the shorter action time for your IV drugs would be worth it.  So my answer is, fuck it.  why not?  anyone else have a reason *NOT* to do this?  I'll pick my P.A.'s brain later about this and respond.


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## Muppet (Jan 15, 2010)

Good question. 
(1): The I.O. goes into the medullary cavity of the bone, a non-colapisable vein per se
(2): The I.O. is pressureized so the fluid can run, again a non-colp. vein thingy
(3): Our S.O.P.'s, state for only one I.O. for trauma, but I guess that can vary.

Remember permissive hypotension thing, if the person is awake and bleeding, stop the bleeding first. If they are unconscious and hypotensive, give enought fluids to support b/p. We can talk more on that another time. Anything that goes i.v. can go I.O. and it works well. Annie, of course the perfussion is compromised but the I.O. is just like the I.V.

F.M.


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## HeloMedic1171 (Jan 15, 2010)

I understand IV and IO are the same as far as meds are concerned, I was just pitching different ideas to fit the requirement.  in the end, I don't have EZ IO, I have FAST 1, so 2 IO's probably isn't an option for me.  like you said, F.M. , plug the hole THEN fill the tank, but I was assuming that was already done....  after thinking about this overnight, and like firemedic said, considering permissive hypotension, 2 IO's may not be the best thing.  do you have an instance in mind where this might be necessary?  

as far as is it possible?  I think so.  I'm just wondering if it's necessary, or potentially dangerous.     but, truthfully, this is a new idea to me. :)


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## HeloMedic1171 (Jan 15, 2010)

also, if someone is THAT fucked up, they'll need blood....  which you can't push through an IO...  so a central line might be your best bet for a secondary access (which would become primary once you get it established.)  for the field guy, this isn't always possible, but we're talking in the ER, yes?  that's absolutely doable.


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## Muppet (Jan 15, 2010)

Blood can be pushed through the I.O. I had a trauma the other day and I I.O.'d the guy. They, The E.D. Shock Trauma team hung blood on a lt. tibial I.O. and it ran well with a pressure bag on it.

F.M.


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## Ajax (Jan 15, 2010)

That's good to know about the blood products.  Back when I was cool, I did a field sx and pushed everything BUT blood through a FAST (MS, Versed, Atropine, Ketamine, Ancef, Rocephin, the kitchen sink).  If I hadn't been in a mudhut, I probably would have tried to push blood product as well.  He damn sure could have used it.

Helo, I'm anxious to hear your PA's ruling on this.


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## Pacer (Jan 29, 2010)

Late to the discussion, and was invited by Firemedic.

Ouch, got caught on a character limit. will split into four or five chunks.

Doc Pacer.

Good points have been made, and it is important to remember the physilogy and relevent anatomy to solve your problem (question). 

First, FM makes the point that had been lost on street medic training for at least two decades I am aware of (I taught and supervised a big city fire paramedic program when the National Standard Curriculum was split into P1 and P2. ALWAYS had an issue with the P2 candidates forgetting EMT-I. Maybe because I first studied from the BROWN ARc book...see intro), is that NO AMOUNT OF FLUID WILL TAKE THE PLACE OF HEMOSTASIS.


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## Pacer (Jan 29, 2010)

Part 2

R.Adams Cowley, who set up the field of trauma care through "ShockTrauma" at the University of Maryland to become the "Maryland Institute of EMS", or MIEMS) quoted the golden hour as the time to reversal of shock, with hemostasis the most important part of that.
We "relearned" the lesson in ODS, OEF, OIF. Tourniquets, blood stoppers and wound packing are FAR More important.
Second, if the patient is "hypotensive" but mentating, current findings published in Mil Med point out findings that you don't want to "pop the clot". In the absence of a head injury, I don't really want a normal blood pressure, I want mentation and maybe a radial pulse, and not much more till I get to ....SURGICAL HEMOSTASIS, ie the FST OR. Hence "permissive" hypotension.


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## Pacer (Jan 29, 2010)

part 3

Third, L (FM) makes the point about oxygen carrying capacity.  Once you have given about 30cc/kg of the clear crap (NSS or RL) you have diluted the NORMAL cell mass (red blood cells) to a critical level. You really need to add blood, especially for trauma/blood loss, at no more than 40cc/kg of resuscitation. Thus, standard 70 kg male (154 # male) we are talking at about 2.8 liters of fluid (call it 3). BUT BLOOD is not yet available. 

Now, if you are using the IO when in a Tech Rescue/TEMS type environment and are luky enough to have RBC, you use WHOLE BLOOD (the Battalion Surgeons CRACK) or PRBC (about 1/3 the volume of whole blood). Don't have dried or dehydrated or shelf stuff that works yet.


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## Pacer (Jan 29, 2010)

part 4

The Military papers I reviewed showed LRRP medics using a colloid/crystalloid formula (for weight savings) but that stuff still doesn't carry oz (Oxygen) and still dilutes the red cell mass (the only stuff that does meaningfully carry oxygen, like 13 volumes vs 0.03 volumes in saline, or hypertonics, or hetastarch type solutions).

So do it really matter if you have one or two before you have the blood to infuse/transfuse?


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## Pacer (Jan 29, 2010)

part 5

Now, it really don't matter whether it is the FAST or EZIO or any other device, if you got another spot available to stick, it won't collapse, so save it for when you can make use of it.

If you need more ports because blood flow sucks, you don't have the skill or want the delay involved in opening a central line, the peripherals are flat, and you have the BLOOD while Bat Surgeon is placing steel hemostats, then open another bone.

Now, some more personal opinion, based on prior experience. How the hell do you retain all the extra doo-dad pieces of a FAST kit? Makes no sense to me, logistically, as it is a kit for ONE site, the STERNUM. Good site, but I'd like to have more options. EZ-IO and BIG allow me not less than 6 site: Both uninjured tibia, both uninjured femurs, both uninjured humeri. (BTW, Humerus is a military expedient)


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## Pacer (Jan 29, 2010)

part 6

I am old school. If I am not sure (due to blast, torso wounds etc) I would place lines (including IO) above AND Below diaphragm, in case the major veins are torn on one or the other axis.

BTW: I have a video of IO contrast injection from the humerus (shoulder) into the heart BEFORE THE INJECTION IS COMPLETE. GREAT access for drugs, MUCH better than IM for pain drugs, and probably better for antibiotics. What else would you want to use if the dike don't have the finger in it?

PS: Since I am one of FM's trainers, I have to say how proud I am of him for his effort. Not my quote, but take 20 min a day to read, and you'll know more than mose docs!

(Dr)Pacer


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## HeloMedic1171 (Jan 30, 2010)

I've been in re-integration and pretty much forgot about this thread.  I did talk to my Battalion Surgeon and my PA.  their answers were short and sweet - "Sure, it's totally possible - but if he's THAT fucked up, you're looking at a greater need for whole blood than you are fluids, and if you're in a clinical/hospital setting, you're better off saving time on the EZIO and sticking in a FAST1 and then going for a mainline."

According to the Doc, that's what we would do if he were ours.  FAST1, then while the rest of the team continues to work on him, someone's going for the juggular.  literally.


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## Muppet (Jan 31, 2010)

Goddam I am turned on  by this thread. Great info. Thanks for the words doc.

F.M.


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