POTD: IO needles: the back~bone~ of EM

Hi everyone and welcome to our new interns! (And cheers to our new senior class and new resus residents! 😍) I’m Ambica and I’ll be the admin resident for the month. Part of this includes writing POTDs aka pearls of the day. For my first POTD, I’m going to talk about using IO needles for a crashing patient and I’m highlighting in blue the biggest take-aways.

It’s helpful to obtain IO access for a crashing patient because the placement can be safe and quick to place (<60 seconds) and can deliver medications at basically the same rate as an IV (which takes more time to place). There’s also a lower risk of bloodstream infections. It’s also been found to have a higher first pass success rate compared to placing a crash central line. 

Here are the optimal locations for needle placement (there are more but I’m listing the common ones and to quickly measure, just use fingerbreadths in place of cm):

- Proximal humerus - greater tubercle, about 2 cm above the surgical neck; helpful if arm is adducted but this is hard to do with chest compressions or the LUCAS machine on; due to the depth, typically should use yellow IO (45 mm) **not preferred in pediatric patients < 6 years old

- Proximal tibia - about 2 cm inferior to the patella and 1-2 cm medial to the tibial tuberosity; preferred option for obese patients

- Distal tibia - 2-3 cm superior to medial malleolus 

- Distal femur - 1 cm superior to patella and 1-2 cm medially

Hold the needle at a 90 degree angle for all insertions except for the proximal humerus location where you hold it at a 45 degree angle

Which size needle do I use? 

- Pink - pediatrics aka infants / toddlers

- Blue - most commonly used for adults and larger pediatric patients

- Yellow - patients with more subcutaneous tissue 

When can I NOT place one: 

1. Fractured bone proximal to IO insertion - absolute contraindication 

2. Recent IO attempt at that site within 24 hours - absolute contraindication 

3. Overlying skin infection

4. Burns

5. Prosthetic limb

6. Underlying bone disease like osteogenesis imperfecta

Here’s a link for an EMRAP video on how to do the procedure. 

https://www.youtube.com/watch?v=KHXSfh2ZRDM

~~

Ambica

https://rebelem.com/dont-forget-about-the-io-in-the-critically-ill-patient/

https://naemsp.org/2023-1-4-iv-vs-io-does-your-site-of-access-matter-in-cardiac-arrest/#:~:text=%5B6%5D%20In%20terms%20of%20flow,rates%20at%20the%20humeral%20site.

https://litfl.com/intraosseous-access/

VOTW: Not Ovar This - A Case of Ovarian Torsion

This VOTW was brought to you by Dr. Nguyen-Phuoc.

A 32 yoF with recent fertility treatment presented to the Bay Ridge ED with severe right pelvic pain associated with nausea and vomiting. The transvaginal ultrasound showed:

- Video 1: an enlarged, edematous right ovary with no color flow and free fluid around it

- Video 2: enlarged left ovary but with color flow

- Image 1: venous flow in L ovary

- Image 2: arterial flow in L ovary

The patient was transferred to MMC, where she was seen by GYN and consented for a diagnostic laparotomy. Intraoperatively, the right ovary was noted to be twisted 3 times and was successfully un-twisted.

Note: Fertility treatments can cause ovarian hyperstimulation syndrome (OHSS), where the ovaries become pathologically enlarged due to capillary leak and third spacing of fluid. The increase in ovarian size from OHSS predisposes patients to ovarian torsion.

Note: Ultrasound is not 100% sensitive for torsion. Doppler findings may be normal as the ovary has a dual blood supply (both ovarian and uterine arteries). If you have a high clinical suspicion despite a negative ultrasound, OBGYN should be consulted.

 Happy Scanning! 

- Ariella Cohen M.D.

References: 

https://coreem.net/core/ovarian-hyperstimulation-syndrome/

https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-genitourinary/ovarian-torsion

VOTW: A Heart-y Effusion

Case: A 62 yoF with a PMHx of CAD presented to the ED as a notification for shortness of breath. She began to worsen and was placed on BIPAP, pressors, and given IV fluids. Despite this, her BP dropped to 57/35 and her pulses became faint. Dr. Yu a bedside echo and saw a large pericardial effusion with tamponade (video 1). She then performed an emergent pericardiocentesis under US guidance and 75 ccs of bloody fluid was removed.

Video 1: subxiphoid view showing a large pericardial effusion with the heart swinging, right atrial, and right ventricular collapse.

Video 2/image 1: Needle tip at the top of the screen inside the pericardial effusion.

Case Conclusion: The patient’s BP immediately improved to 189/94 and she was weaned off of pressors before being admitted to MICU. Cardiothoracic surgery was consulted and the patient is scheduled for a pericardial window.

For more information on how to perform a pericardiocentesis in the subxiphoid approach: https://litfl.com/pericardiocentesis/

Happy scanning! 

Ariella Cohen