Cite this post as:
Scott Weingart, MD FCCM. How to Place and Secure an IO in a Peds Patient. EMCrit Blog. Published on July 1, 2012. Accessed on December 4th 2022. Available at [https://emcrit.org/emcrit/how-to-secure-an-io-in-a-peds-patient/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: July 1, 2012
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
You finished the 'cast,
Now Join EMCrit!
As a member, you can...
- Get CME hours
- Get the On Deeper Reflection Podcast
- Support the show
- Write it off on your taxes or get reimbursed by your department
.
Get the EMCrit Newsletter
If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the Resuscitation and Critical Care goodness.
This Post was by the EMCrit Crew, published 10 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.
Scott, Great post, but one issue is this statement “We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill.” Just because residents may not be initially as adept at placing IOs, it doesn’t mean they shouldn’t be placing them. Like any procedure, if not done as a resident, that skillset won’t be there as an attending–when he/she is expected to be the final authority and definitive proceduralist. Keep in mind that that particular critical care transport medic at one… Read more »
I hear you. It is one of the toughest issues we as EM Academic Attendings have to cope with. How much training-on-the-patient is actually fair or right. For some things like ultrasound, there are now worries. For a pediatric IO, where no matter how well I describe the technique, it comes down to muscle memory–it is a near-impossible-to-solve problem. Good task trainers are the answer, but I’ve found very few procedures where they exist.
Vidacare makes pretty darn good task trainers for proximal humerus and proximal tibia.
So how do we fix this? The answer is not to have attendings place them until they retire, because there will not be anyone to place them after that. You must be able to allow for the future attendings to train. Yes it’s difficult when it’s a real patient but this is how everyone has learned.
Doing a procedure because it’s muscle memory for you is not the right answer because at one point in your career this was not muscle memory. The only way it became muscle memory was by doing it.
I understand your point. I think that the appropriate time and place for a green resident to “train on the patient,” as Scott put it, NOT at a outlying facility or in a helicopter. We simply do not have the hands or the resources.
In a trauma room or ICU supervised by an attending? That’s not my area, I won’t step on toes.
its a bit off topic but Jeff raises a good point. Medicine has always been an apprentice model of training and mastery. You cant simulate everything . Bruce Lee once said, you can try to teach swimming on dry land as much as you want, but nothing beats getting into the water! Patient safety and quality care issues challenge us , responsible for training the next generation, as Scott says. Personally I take the view point that teaching and supervising someone to perform a life saving skill is a favourable balance of the patient safety vs training needs equation…in general… Read more »
To help protect my IOs (even in adults) I place a roll of tape over the top of it so the roll lies flat to the skin. I then secure it with long strips of tape the te skin. That way the tape takes the knocks rather than the IO.
Thanks, Rebecca, for these excellent tips. Your comment about some folks suggesting proximal humerus is the preferred site is right on target. I’m one of those folks. Because of the lower intramedullary pressure there, you achieve simultaneously a 5x greater flow rate (vs prox tibia) AND less patient discomfort. Your target is much bigger, so despite more overlying soft tissue, I think with training that proper placement is actually easier at the humeral site. If you’re running a code (and you believe that epi works), humerally administered epi will get to the heart in about 0.5 seconds, just as if… Read more »
I actually learned about the proximal humerus as a preferred site from your talk at CCTMC this year. I haven’t had a chance to try it yet.
Rock on! It’s a great conference. Hope to see you in Austin, April 8-10, 2013, for CCTMC 2013. Call for speakers is ongoing now and due August 1, 2012; go to ampa.org for more info. And give that proximal humeral site a try next time you’ve got a patient needing an IO.
Here are my two bits on the whole IO experience. My background is in Prehospital medicine and ER as a nurse in a level one Adult and Peds Trauma center. The errors that I have seen in practice come back to lack of quality education prior to deployment of a new device. Also, needle choice and site choice is key. Not all peds pts get the 15mm needle most get the 25 mm needle. Pushing the needle through the skin until you hit bone and then looking for a black line is a must. If you see a black line… Read more »
Wow, Kevin! Amazing additional information–icing on the cake.
So, to weigh in on this as a lowly resident and EMCrit fan since MSIII: I can see how folks would prefer not to let residents put in lines, IOs, etc. It creates a potential problem for care of the individual patient – but saves our future patients a great deal of suffering. Everyone has a first. I’ve noticed a truly distressing tendency for non-military-trained PAs to bar residents from procedures, and I understand that some folks are very results-oriented. As medical professionals, though, shouldn’t we work together to pool our knowledge rather than to create silos of care? This… Read more »
thanks for commenting, I agree with all you said above. For most procedures it is not a problem (chest tubes, etc.). It really comes down to vascular access procedures b/c no matter how much you talk your learner through it, it really comes down to needle feel and control. I think residents should have to practice with a vessel trainer and an ultrasound probe with a wire to pass 20 or thirty times (which you can do in 1 session). This would give me a resident that is very ready to do a central line on their 1st real patient… Read more »
I understand your point. The “no residents” rule is ONLY on transports and at outlying facilities. As I said above, what happens in the trauma room is between you and your attending. There are several reasons this rule came about: 1. We have a small team and everyone has their defined roles. The resident needs to be getting a FULL report from the physician that was caring for the patient and reviewing labs/imaging/etc. The critical care paramedic(s) (with the help of the sending facility RNs) is then working to stabilize and package the patient for transport. If the resident gets… Read more »
Kevin Guenard’s post mentions something of incredible importance that deserves repeating – in *many* pediatric patients, the pink EZ-IO needle (labeled for 3-39 kg) is not long enough to penetrate flubber and enter the intramedullary cavity. We have had several infants in whom the pink needle wasn’t long enough, but older children in whom it is. Opening the needle set to find out the device isn’t of appropriate length for a given patient is wasteful – I’m at a point that I really don’t see the point in carrying the 15 mm needle set. Kevin I wonder what your thoughts… Read more »
Scott, In reply to your question about the need to carry 15mm needles, I can say this. Our hospital/ems division oversees 40 ems/fire agencies, our advice to them is not to buy the 15mm needle and focus on the 25 and 45mm needles instead. We found agencies were waisting a lot of 15mm needles and as mentioned before most kids get a 25mm needle. As far as teaching new medics/nurses/docs how to put in an IO, it can be tricky. Most importantly placing an IO in a preemie can be the most challenging. I recommend and have used a raw… Read more »
Kevin,
Amazing idea re: the egg. I think that is a perfect training solution.
i am reading this all 6 years post original publication.
the comments and discussions are all so appreciated.
very very cool
tom