EMS Medication Administration - Intraosseous (IO) Route

EMS providers should have comprehensive knowledge of intraosseous (IO) medication administration within their scope of practice to ensure patient safety and effective treatment. 

Here are the key points they should know:

1. Indications and Contraindications

• Indications:
• IO access is typically used when IV access is difficult or impossible, especially in emergencies.
• Common scenarios include cardiac arrest, severe shock, trauma, and other situations requiring immediate vascular access.

• Contraindications:
  • Fractures in the targeted bone
  • Previous orthopedic procedures at the insertion site
  • Infection at the insertion site
  • Osteoporosis or other bone abnormalities

2. Anatomy and Site Selection

• Common IO Sites:
• Proximal tibia
• Distal tibia
• Proximal humerus
• Sternum (primarily in adults)

• Site Selection Criteria:
  • Age of the patient
  • Accessibility of the site
  • Absence of contraindications like fractures or infections

3. IO Device Knowledge

• Types of IO Devices: Familiarity with various IO devices such as manual needles, battery-powered devices (e.g., EZ-IO), and spring-loaded devices.

• Device Operation: Understanding the specific operation, insertion technique, and maintenance of the IO device they are using.

4. Insertion Technique

• Preparation:
• Use of aseptic technique to prevent infection
• Selection of appropriate needle size based on patient age and size

• Insertion Steps:
• Properly positioning the patient
• Identifying the correct anatomical landmarks
• Using correct insertion angle and depth

• Confirmation of Placement:
  • Aspiration of bone marrow or blood
  • Easy flushing of saline without resistance
  • Securing the IO needle to prevent dislodgement

5. Medication Administration

• Types of Medications: Most medications that can be given IV can also be administered IO, including fluids, blood products, antibiotics, and emergency medications.

• Dosage and Rate:
• Ensuring correct dosing similar to IV administration
• Awareness of potential variations in absorption and onset of action

• Flush Protocol: Flushing the IO line with saline to ensure patency and proper delivery of medications.

6. Complications and Management

• Extravasation: Recognizing and managing extravasation (leakage of fluid into surrounding tissues).

• Infection: Preventing and identifying signs of infection at the insertion site.

• Compartment Syndrome: Monitoring for and managing compartment syndrome, a serious condition caused by increased pressure in a muscle compartment.

• Fat Embolism: Awareness of the rare risk of fat embolism, particularly in long bone insertion sites.

7. Pain Management

• Local Anesthesia: Use of lidocaine or other local anesthetics to reduce pain during insertion, especially in conscious patients.

• Post-Insertion Pain: Monitoring and managing any pain or discomfort associated with the IO line.

8. Training and Proficiency

• Simulation Training: Regular training and practice using simulation models to maintain proficiency in IO insertion and management.

• Certification: Ensuring certification and adherence to protocols established by the EMS service and medical oversight.

9. Legal and Ethical Considerations

• Scope of Practice: Adhering to the legal scope of practice for their certification level and local regulations.

• Informed Consent: Whenever possible, obtaining informed consent from the patient or their guardian before IO insertion.

• Documentation: Accurate documentation of the indication, insertion site, device used, medications administered, and any complications encountered.

Conclusion

Effective IO medication administration requires EMS providers to combine detailed anatomical knowledge, practical skills, and a strong understanding of the indications, techniques, and potential complications. 

Continuous training and adherence to protocols are essential to ensure the safety and efficacy of this critical intervention. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Philbeck, T. E (2010) Pain Management with the use of IO. Journal of Emergency Medical Services. https://www.jems.com/patient-care/pain-management-use-io/ Accessed June 10, 2024

EMS Peculiar Patient Presentations - Compartment Syndrome

Compartment syndrome is a serious medical condition that occurs when there is increased pressure within a muscle compartment in the body. A muscle compartment is a group of muscles, nerves, and blood vessels surrounded by a tough membrane called fascia. 

When the pressure within a compartment becomes too high, it can lead to inadequate blood flow to the muscles and other tissues within the compartment, causing damage and potentially leading to serious complications. Compartment syndrome most commonly occurs in the arms and legs.

Key points that EMS Providers need to know about compartment syndrome in the prehospital setting include:

Causes: Compartment syndrome can be caused by various factors, such as trauma (e.g., fractures or crush injuries), prolonged pressure on a limb, or conditions like bleeding disorders. It can also occur after surgical procedures.

Signs and Symptoms: EMS providers should be aware of the signs and symptoms of compartment syndrome, which may include severe pain that is out of proportion to the injury, swelling, tightness, numbness, tingling, weakness, and decreased range of motion in the affected limb. Pain that worsens with passive stretching of the muscles is a classic sign.

Rapid Assessment: In the prehospital setting, quick assessment is crucial. EMS providers should evaluate the patient's limb for signs of compartment syndrome and consider the mechanism of injury. A high index of suspicion is important, especially in cases of trauma.

Immediate Immobilization: Immobilization of the affected limb is important to prevent further injury and minimize the risk of worsening compartment syndrome.

Avoidance of Circulatory Compromise: Providers should avoid placing constricting devices (like tourniquets) on the limb, as these can exacerbate the condition. Instead, focus on ensuring that the limb is adequately supported and not subject to excessive pressure.

Prompt Transport: Compartment syndrome is a medical emergency. If you suspect compartment syndrome, the patient should be transported to a medical facility as quickly as possible.

Communicate With Hospital: It's crucial to communicate your suspicion of compartment syndrome to the receiving hospital. This can help them prepare for the patient's arrival and expedite the necessary diagnostic tests and treatment.

Treatment: Definitive treatment for compartment syndrome typically involves a surgical procedure called a fasciotomy, where the fascia surrounding the affected compartment is cut open to relieve the pressure and restore blood flow. EMS providers do not perform this procedure but should facilitate the patient's access to definitive medical care.

Complications of untreated compartment syndrome can be severe and include muscle and nerve damage, permanent disability, tissue death (necrosis), and in severe cases, amputation. Early recognition and prompt intervention are critical to minimize these complications. 

EMS providers play a crucial role in the initial assessment, stabilization, and transportation of patients with suspected compartment syndrome to ensure they receive timely and appropriate medical care.

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