As we near the end of the semester and NREMT paramedic classes begin to practice for their NREMT exams, I thought it would be time to review some of the skills that are needed for both the BLS and ALS versions of the test. I’ve been covering IO drills lately since our friend, Eric Augustus wrote such a good piece about it over at the EMS Haiku blog.

I cover all of these skills over at the MedicCast Extra site if you want to have a good place to review and download NREMT test tips for yourself.

Eric, however, was kind enough to send me this info on his use of intra osseous infusion in the field. Here is what he sent my way:

Experiences with IO

I’ve been exposed to IO for almost 20 years, ever since my first PALS class. It wasn’t until I came to my present job that I’ve ever had the opportunity to actually use it.

“My first time”

We were dispatched to a child run over. The little guy (18 months old) had been accidentally run over by a dual-axle trailer. The tires straddled the patient, and dad was unable to lift the trailer off of him and pull him out at the same time. He had to drop the trailer back on top of the kid and run for help. Help was mom.

We were about 11 miles away when we were dispatched. I put in a call for a helicopter. As we arrived, I found the patient purple from the chest up and with a broken femur. I had heard about Traumatic Asphyxia in school and knew that it was VERY BAD. I told the first responders that I wanted the patient naked and in a KED. I returned to the ambulance and called the hospital. I was convinced that he would die at any moment.

“Don’t bring him here” was the response from the doctor. We decided to bypass the local hospital, drive like hell for the nearest trauma center, and hope for a helicopter intercept. After a 7-minute scene time, we were off, driving down an old logging road, headed for the highway. I had 2 others in the back with me – my partner and a first responder. Another first responder was driving.

My partner was in charge of getting & monitoring vital signs, and the first responder was responsible for airway. Airway was not really a problem, as the patient never stopped yelling and/or screaming. After cutting all of his clothes off, I decided to stabilize his leg. We don’t carry a traction splint that small, so I folded a SAM splint in half, placed it between his legs, and used Coban to strap both legs together with the SAM splint in the middle.

I missed my IV attempts. We have to try twice before our protocols let us do IO. At that time, we used the Jamshidi IO needle. I gathered all the equipment, found my landmarks, took a deep breath, and started twisting the needle into his leg. He yelled a little louder, but I placed the needle. I managed to aspirate marrow, but had a hell of a time infusing fluid. In hindsight, I may have had the needle too deep. But, it worked and I was happy.

After finding the highway, we met the helicopter and transferred the patient. He was home in a week. Turns out that traumatic asphyxia isn’t nearly as deadly in children as it is in adults.

#2

I don’t remember this one as much. It was another child – probably 2 years old or less. The call came in as a seizure. He was lethargic (probably postictal), but had a heart rate over 200, wheezes, and a rash. It was another quick scene time. We got the hell out of there, and were headed lights & sirens for the hospital. Again, I tried for an IV but was unsuccessful. Mom was strapped into the gurney, holding her son.

I explained what I was going to do, and that it would be painful and not much fun to watch. I also explained the need for access, and how sick I thought her son was. She agreed to the procedure. I gathered all my equipment, found my landmarks, and took another deep breath. This one was a little different – landmarks were there, but it wasn’t as smooth as the first one. I got the needle in place, and felt it was stable.

Mom was not impressed. She was yelling at me by the time it was over, and almost revoked permission for the procedure. In retrospect, I will never do an IO, especially with the old Jamshidi needles, while my patient is being held in mom’s lap.

By the time I had it secured, we were at the hospital. I didn’t have time to infuse any fluids, and by the time the ED staff got around to fluids, the needle was no longer in the bone. During this time, we had IO access for adults as well. We stocked the Bone Injection Gun (B.I.G.) on our rigs, but it was never used. Personally, I found it too scary to use. It seemed too inhumane, imprecise, and very powerful. Most of my co-workers felt the same. In fact, I had the opportunity to use it, but never did, and was chastised twice by my physician advisor twice because I should have used it. One was on an adult male trauma patient, and the other a older male with a dissecting AAA.

Era of EZ-IO

We started using the EZ-IO last year. Our protocols allow its use to deliver life-saving fluids or medications if we’ve missed 2 IV’s. I’ve used it 5 times since, on 2 children and 3 adults. The first use was on a 6 year-old with terminal brain cancer, seizures, and a new onset pneumonia. He was very sick. This was not your typical 6-year old, either. He weighed well over 100 pounds.

I had just had this guy as a patient on my last shift, and knew he didn’t have any veins. He was very sick this time – obtunded and in respiratory failure. I told his mother what my plans were and we loaded him up. Before we left, I placed the needle and started fluids. The insertion was quick and precise. In fact, my partner had turned away for something, and the needle was in before he could turn back around. There was no response from the patient. The second use was on a 1 year-old with Tay-Sachs Disease and had been seizing. He was known to have status seizures, and so I wanted some access if he started seizing again. I tried once for IV access, missed, and without a missed beat, went to the EZ-IO. I remember piercing the skin and then bouncing right off the tibia. That needle is sharp! Getting my bearings again, I drove the needle in, got my marrow draw & started to flush some saline. The patient started writhing in pain during the bolus. This was the only indication of pain I’ve ever seen using the EZ-IO.

#3

The third use was on a 50’s year old female OD patient. She was obtunded with snoring respirations. The fire department was unable to place an IV, so I made the decision for IO. Once again, it was a very quick and precise placement without any patient changes. My fourth use was on another adult – a 60’s year old female with hyperglycemia. We were able to place the needle and infuse a large amount of fluid before we arrived at the hospital, shortening her stay there.

As mentioned in my blog, I just used it again the other day on a 19-year old in profound septic shock. I placed the IO in the hospital ED before we left, and was able to infuse almost 2 units of blood in the 1 hour transport to the tertiary care facility.

Wrapping Up

It’s been my experience that IO is a very useful tool, and when used appropriately, can have beneficial results to our patients. Using new technology, such as the EZ-IO, reduces the reluctance and apprehension, and increases success for Paramedics in the field (and even in the hospital, where we’ve placed 2 IO’s for the ED staff before they got the EZ-IO for themselves).
Eric Augustus
Paramedic in Oregon

Thanks, Eric for that very thorough look at the IO needles in the field.

For those of you who have not seen the EZ-IO drill at work. Eric Augustus pointed me to this video of the process. Check it out:

My friend, Eric Augustus recently wrote a great post about decisions he had to make regarding getting a patient in septic shock enough fluids to make the dopamine he was giving effective.  He got permission to use IO (intraosseous) access to get another line.

He writes a great tale of how this tool is going to change the way we do things in the field.  For those of us who actually get to play with them, anyway.  I have to say that my area is really dragging their feet on this one.  The tool has proven itself in many areas surrounding our region of the state of Maryland but still we don’t have tacit approval to go ahead and get the EZ-IO system, or anything like it.

I hope that changes soon.  I’m glad Eric got a chance to use his, though.  Read more of his exploits and some pretty good Haiku poetry on EMS, too.  Go to emshaiku.blog-city.com to check out the EMS Haiku blog.

Our friend, Tim Pruyn from NSW, Australia sent me some follow-up information on the snakebites episode recently. Compared to Australia’s poisonous snake situation, the U.S. has it easy. Here is what Tim had to share:

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G’Day Jamie,

Listen to both the MedicCast and Nursing Show podcasts with the snake bites interview.

Australia is home to 11 of the world’s most venomous snakes. Out of the top 25 most venomous snakes in the world, Australia is home to 20 of them (see table). According to the Australian Venom Research Unit (AVRU), there are approx 3000 snakes bite victims per year in Australia, with between 200 and 500 victims receiving anti-venom. Between 1979 to 1998 there were 53 fatalities due to snake bites in Australia. (source: Australian bureau of statistics)

World’s Most Venomous Snakes

Which snake species is the most venomous depends on the measure used. The average or the maximum venom yield from milking could be suggested, but these measures can be criticised as not reflecting the impact of a real bite. The measure generally acknowledged as best reflecting how dangerous a snake’s venom is is that of LD50. The lower this number, the less venom is required to cause death. By that measure, the most venomous snake in the world is Australia’s inland taipan (Oxyuranus microlepidotus). The table below gives the top 25 species in order, their LD50, and their distribution.

Snake Species LD50* Distribution
1. Inland taipan 0.025 Australia
2. Eastern brown snake 0.053 Australia
3. Coastal taipan 0.099 Australia
4. Tiger snake 0.118 Australia
5. Black tiger snake 0.131 Australia
6. Beaked sea snake 0.164 Australia
7. Black tiger snake 0.194 - 0.338 Australia
8. Death adder 0.400 Australia
9. Gwardar 0.473 Australia
10. Spotted brown snake 0.360 (in bovine serum albumin) Australia
11. Australian copperhead 0.560 Australia
12. Cobra 0.565 Asia
13. Dugite 0.660 Australia
14. Papuan black snake 1.09 New Guinea
15. Stephens’ banded snake 1.36 Australia
16. Rough scaled snake 1.36 Australia
17. King cobra 1.80 Asia
18. Blue-bellied black snake 2.13 Australia
19. Collett’s snake 2.38 Australia
20. Mulga snake 2.38 Australia
21. Red-bellied black snake 2.52 Australia
22. Small eyed snake 2.67 Australia
23. Eastern diamond-backed rattlesnake 11.4 North America
24. Black whipsnake >14.2 Australia
25. Fer-de-lance >27.8 South America
*LD50: mg/kg in saline by subcutaneous injection in mice

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Thanks, Tim. For the rest of you — do you have information to share here on the MedicCast? Send in your own comments or articles to share with the other listeners.

A new AHA article on hypertension is now available.  In this article, the authors look at treatment resistant hypertension.  They look at prevalence, possible causes, and potential treatment modalities.

Here is the link to the AHA page on hypertension.

As EMS providers, it is always helpful to understand some of the whys behind the ways our patients present.  What are the medication options now and what are the physicians looking at for the future.

EMTs and paramedics need to know a bit about the medications that our patients are taking and how their primary care physicians are managing their chronic conditions.   Learn a bit about the meds that are most common for your patients.  Be prepared to explain back some of the common side effects for these meds.

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Check out the MedicCast Extra for more easy access for all of the meds, skills, and testing tips needed by any EMT, paramedic, or emergency medical services professional.

I got this information via Maryland Poison Control’s monthly newsletter Toxtidbits.

You can download your own copy or subscribe here:

http://www.mdpoison.com/publications/current.html

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Phenytoin (commonly known by the brand name Dilantin® ) has been used since the 1930’s as an anticonvulsant and is still a first-line drug used for some seizure disorders. Many overdoses with phenytoin are reported to poison centers, but fatalities are rare.

Absorption of oral doses of phenytoin is often erratic and delayed. It’s not unusual to see gastrointestinal absorption continue for several days. Phenytoin is highly protein bound and rapidly distributed to all tissues.  Therapeutic levels are 10-20 mcg/mL.. Labs routinely test for total phenytoin; however, only  free or unbound phenytoin is responsible for clinical effects. More than 95% of the drug is metabolized by the liver. The half-life of phenytoin is 6-24 hours with therapeutic doses but is prolonged in overdoses, to 20-60 hours.

Acute phenytoin toxicity produces mainly neurologic symptoms that may persist for days to a week or more. Phenytoin concentrations greater than 15-20 mcg/mL are associated with horizontal and/or vertical nystagmus, ataxia is seen with levels greater than 30 mcg/mL , and slurred speech, confusion and lethargy appear at levels greater than 40-50 mcg/mL. Large overdoses may also result in tremor, delirium, hyperreflexia, dyskinesias, hallucinations, and coma. Nausea and vomiting can occur following phenytoin ingestions because of the large amount of undissolved drug in the stomach. Respiratory depression rarely occurs. High doses of intravenous phenytoin or rapid infusions can result in hypotension, bradycardia and dysrhythmias due to myocardial conduction depression. These cardiovascular effects are thought to be due to the propylene glycol diluent in the parenteral form of phenytoin. Cardiovascular toxicity following oral overdoses has not been reported; therefore, patients who ingest large amounts of phenytoin do not need cardiac monitoring.

Treatment consists of supportive care and activated charcoal. Repeat doses of charcoal are often recommended to prevent further absorption of any drug that persists in the GI tract. Ataxic patients should be observed closely and steps taken to prevent falls. Because of its erratic absorption, phenytoin levels should be repeated every six hours after an acute overdose.

I like the article I found recently on rural telemedicine. It talks about linking patients in remote areas of the country and even the world with health care specialists and testing that will open up incredible possibilities for these people.

Imagine a patient who may have an internal bleed. Local health care is unable to adequately assess the patient locally. Do you transport the patient by ground for hours to a specialty center only to find that they didn’t need to go there? This technology offers these borderline patients a chance to be “seen” by doctors who are located elsewhere (perhaps around the world), and have the assessing team on location be guided in their assessment by the specialist.

The EMT, paramedic, nurse, or local doctor act as the eyes and ears of the specialist, transmit data, video, or audio files to the distant location and have a better chance at saving the patient the need for extended costs of specialty care and transport if they don’t need it.

Identity theft is a big issue right now.  People are having their lives turned upside down by having their financial records compromised.  Imagine having your medical records compromised as well.

Patients are having their medical safety endangered when their stolen identity got to the hospital ahead of them.  Picture this:

The thief receives treatment in someone else’s name

The real person shows up at the hospital and their (fake) record is already on file

thief has no allergies, real person does and has an anaphylactic reaction — Surprise!

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The lesson here, as some of our agencies switch to electronic mobile record keeping and may have access to patient records from previous transports –  Be a thorough historian.  Verify as much information with the patient as you can and don’t slack off on the important steps like asking about patient allergies and medications.

Researchers at Rutgers University have created a liquid bandage for use in the field and say that it is appropriate for use in combat situations.  The FDA released the product for marketing and called it similar to other liquid bandage products on the market.

Read the article here.

The University’s Center for Military Biomedical Research  has partnered with Georgia company BioCure to produce and market the product.  The spray on bandage consists of two polymers that combine in the spray to form a gel over the wound area.  It will be called GelSpray Liquid Bandage.

A recent study from the New England Journal of Medicine compared coronary artery bypass graft surgery to the placement of drug coated stents.

Read the article about it here.

There was a lot of hope that the newer drug coated stents would provide a better and safer alternative to cracking the chest and performing a CABG.  However, the newest study seems to indicate that the outcomes for a traditional bypass are still better than with stent placement.

Does this effect us in the field?  Not really, but it is important to understand that this does not replace the need to get patients with suspected MIs to the nearest catheter lab or cardiac specialty center.  The areas of blockage still need to be imaged so that the number and locations of CABGs can be determined.

It’s always a good idea to maintain an understanding of current cardiac treatment effects since we often see people in the field with complications from these treatments as well as those with new onset of infarctions.

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