It’s aggressive, sure… But, I’m going to reach for My EZ IO and get access just as quick, and maybe quicker since I’ve done that about a dozen times. I still am open to learning something new and having more tools will give me something when I have a patient with busted upper and lower extremities.

Jose Diaz PA-C

Not too aggressive if everything else is failing and pt is crashing. With that being said, big vessels are usually easy to hit with landmarks or US. The only delay with US for me is time to put on sterile cover probe (10 secs) as typically fired up and ready to go with sick pt coming in. I can see how this technique can be very fast, but with rarity of application, may be more time consuming than regularly practiced methods especially in morbid obese.

Yep it is aggressive in my opinion. I get about three or four patients a year in the ICU…some trauma and some medical that I just can not get access. Either the wire will not feed or something. In the ICU usually I am not as pressed as in the ED unless they are really crashing. I like the IO approach the more and more I see it used in codes and ED’s as well as the field by EMS. I will usually try a line first. Honestly I have only had to go the IO route once and that was in a code on the medical floor and the code cart was not stocked with a good ole fashioned central line kit.

I have watched a surgeon do cut downs on a patient bleeding out and still almost could not get access. It took several minutes and I was a bit nervous.

The trauma patient with fractured limbs may be a bad candidate for IO and I can see how having this skill is good to have in your tool box.

One more comment I have to make is this. I have watched a number of residents try and try to get access using ultrasound in the groin during a code. Usually this is a challenge. If they are overwt, then feeding the wire is a bit of challenge that is sometimes a fail. In the era of aggressive cpr it is rare that we stop compressing the chest so most people shy away (at least in internal medicine) from placing a subclav in a code. Where do you ED folks usually go when the traumas come in… Groin? Subclav? IJ? My observation is that most of the surgery guys put in subclav and that most ED guys still place IJ’s in the ED patients. I used to go femoral in most of my codes as a resident, but as a fellow I started to go straight for the right subclav. I dont need US and the landmarks are great even with a bmi of 40. It literally takes 10 seconds to get access and if you use a cordis, you dont have to waste time with dilation and then insertion. You do not need a blood pressure to hit the… Read more »

Learned this trick from Aurelio Rodriquez during a stent at Shock Trauma back in the 90s. Its as close to instantaneous access as you can get. Flail potential is practically non existent.

Thanks for sharing this technique Scott. In the perspective of life and death, I don’t think it is too aggressive. It is nice to read about this procedure for two reasons: 1. It might be the solution to a specific patient we will encounter. When everything else fails or is unavailable. 2. It is a nice example of thinking outside the box and come up with a “clear-cut” solution to a serious problem. I see three difficulties: 1. Due to anatomical variation it might be difficult te locate the vein. http://www.minnisjournals.com.au/_images/articles/pdf/article-pdf-0094.pdf On the other hand, it is unlikely that you will not be able to find a vein where you can place your line in (although in severe hypovolemia it might be more difficult). 2. When making such an incision, it is possible to cut an adjacent nerve as well. http://scientia.wikispaces.com/file/view/tl526.jpg/30332559/tl526.jpg 3. How can we gain the competency which is needed to master this procedure? It is not something that we can practice in a non-emergency setting. Personally, I would prefer placing an introducer catheter in the internal jugular right, with ultrasound. Our cardiac anesthesiologist sometimes use the innomate vein. This might be a nice alternative as well. Anyhow, thanks… Read more »

I appreciate everyone’s thoughts. The above-picture was my first one supervised by Director of Trauma at Shock Trauma when I was a fellow. It was my first; it literally took <15 from time of asking for knife to blood flowing into the patient. This patient had multiple, and failed, attempts at access by IJ by an attending trauma anesthesiologist, bilateral subclavians, and groins. He had an IO in – but he needed rapid transfusion. Peripheals were impossible. I would tell you that since that time – I have practiced more and become quicker. Well – it's so ridiculously easy that I think now that I'm on my 10th – i'm maybe a second faster? The point is – it's simple and easy and doesn't even need practice probably. If you want to practice though – cadaver lab would work just fine. The most difficult part is grabbing the vein with smooth forceps and maneuvering the catheter into it. A few responses to the above comments: The anatomy between all patients of course is different: but that's more so with regard to where the saphenous inserts into the femoral vein, etc. It's sort of like the anatomical variations of people with… Read more »

One more thing – how deep do you cut? You cut past the epidermis and dermis into sub cutaneous fat. If you hit muscle you are too deep…

Why is the catheter placed distally? It seems like it would more likely become obstructed by the valves within the venous system that prevent backflow.

Thanks for adding another tool to the toolbox. Much appreciated.

I just want to remind everybody that not all IO access is equal. Proximal humerus = 5x greater flow rate than proximal tibia. You can easily blast 5L/hour of crystalloid into a patient with a pressure bag using a proximal humeral IO (not that we would ever do that in trauma, of course.) I know some have expressed concerns about hemolysis if blasting PRBCs into an IO, but thus far, to my knowledge, those concerns are only theoretical, and those who have looked for evidence of hemolysis haven’t found it.

That said, it’s fantastic to have another option for quick big vascular access, so again, much appreciated.

Back to the future, sort of… the saphenous cutdown was the standard when I was training and we had to “prove” that femoral lines via Seldinger technique was as good or faster. This study was done during my residency at Northwestern: http://www.ncbi.nlm.nih.gov/pubmed/8135430 and consisted of 78 patients randomized to cutdown or femoral line. Time to infusion 6.65 minutes for cutdown, 4.56 min for femoral line. If you read the article, also look at the time to completion of procedure (much longer for cutdown) and rates of failure to infusion (6 in cutdown group; 3 in line group, pts transferred rapidly to O.R.). These procedures were performed by EM or surgical housestaff or attendings (though not specified in the article, my recollection was mostly housestaff). We did a lot of cutdowns back then. Despite my above rebuff of the cutdown, I’m happy for the podcast and post and I’m glad that I have this skill in my quiver. The technique that was prevalent back then did not involve the distal saphenous nor the femoral, but rather the very proximal saphenous, a technique described and popularized by Dronen in his 1981 Annals article http://www.ncbi.nlm.nih.gov/pubmed/7235344 Dronen later tweaked his technique in a Roberts… Read more »

I did a groin cut down +10yrs ago. Good thought to go a bit distal. Same approach in upper arm if pelvis rogered? Prob too much clockwork…..

I think some of you may be missing the point. This technique is easy and only requires a knife and pickups. Worry about tying off the distal vein after (or just clamp it).

You simply cut until it the leg bleeds, grab the vessel and insert the catheter. No clamp no retractor no thinking no dissection. This technique is actually faster than a traditional placement of a central line. I wouldn’t hesitate to use this technique in the setting of a patient who desperately needs access and resuscitation for trauma.

My patience for waiting for access in a patient in extremis who needs stat access is very low.