A lot of you were asking about how to know when to go for an intraosseous (IO) during emergency situations such as CPR. IO access is a great option for when a patient is coding and you have already attempted TWICE without a successful IV placement. IV access is still preferred over IO access because drugs like epinephrine work better when they are given intravenously.
There are two common spots for IO placement – the humerus or the tibia! Personally, I find that IO placement in the TIBIA makes the most sense during CPR situations because if the patient needs an endotracheal tube (ET) placed or has one placed already. There is already a lot going on by the upper body/airway area so instead of having team members on top of one another I find it better to stay towards the other half of the body.
I encourage all of you to check out the IO start kits if you have any in your department. It can be intimidating because they come with a drill but it’s important for you to get comfortable using them. IO placement during codes is a great time to practice your skills. I suggest letting your charge nurse know that you are interested in an IO insertion and ask if you can place one during the next code that comes in. Or ask to watch him or her place one then you can insert the next one if a second code comes in.
The external jugular (EJ) vein is another commonly accessed area when a peripheral IV is not possible. Depending on what state or institution you work at, only physicians or advanced practice providers (nurse practitioners or physician assistants) may be allowed to insert these. If you work on the ambulance, many times you are trained into EJ placement also, in this case check with your facility to see if you are allowed to perform EJs before you attempt to place one.
In my post from yesterday, I spoke about going for the big juicy AC whenever possible during codes. But what if there is no juicy AC? I recommend looking distally (downward) for a vein rather than above the AC. Why? During CPR, the body is constantly being moved because of compressions. This adds to a greater risk of blowing the IV if you knick the inside of the vein. If you do blow the vein, you won’t be able to use that same vein any lower than that insertion point because anything you infuse through one bellow your failed attempt will come out like a mini waterfall or disperse within the tissues.