January 25, 2018

Background: Placement of vascular access for administration of resuscitation drugs and fluids is a common procedure in the management of out of hospital cardiac arrest (OHCA). While intravenous (IV) placement has been the standard approach for decades, intraosseous (IO) access is rapid and safe and may be the preferred approach due to fact that the bone marrow does not collapse during shock states as peripheral veins often do. Despite it’s advantages, there are concerns about IO placement because of the potential for drugs to pool in the marrow and not circulate. Prior studies have shown an association with tibial IO placement and decreased rate of ROSC though no association with worse neurologic outcomes (Feinstein 2017).

May 4, 2017

Background: IV access is one the most important interventions that must be performed in effectively managing patients in the Emergency Department.  It is part of “Circulation” in the ABCs acronym and is even first in the “IV, O2, Monitor” phrase that we have become accustom to hearing.  Although experienced ED nurses can obtain access quickly and without much difficulty in most patients, there remain a handful of patients that will present to the ED where standard peripheral access is unable to be obtained after multiple attempts.  What is the next step? Peripheral placement of an IV using ultrasound can be a great next step if timing permits, but this too can be troublesome in patients who are difficult to access, especially if dehydration is present.  IOs have become more popular but are painful when medications are given through them, thus making management more difficult in patients who are alert.  Also IOs are limited in regards to what lab testing can be performed.  Central lines are not worth the risk if IV access does not need to be central or if access is only needed temporarily.   External Juglar IV placement can have similar difficulties as traditional peripheral access especially, in patients with a large body habitus or who have had repeated EJ cannulations. What if a peripheral IV was placed into the internal jugular vein (Easy IJ)?  It is an easily visualized structure on ultrasound and cannulating it is a skill that is familiar to most Emergency physicians.  Is this a safe approach?

April 24, 2017

Background: We have all taken care of patients in whom IV access is difficult due to a multitude of reasons including repeated prior IV access, advanced vascular disease and shock. This often creates delays in patient care, increases ED length of stay, and uses up ED staff that have other patients to care for. Many providers have resorted to using IO access, particularly in critically ill patients due to speed of establishing access.  In stable patients, however, this may be a less desirable.  Ultrasound guidance has been a great addition in these patients.  Ultrasound guided peripheral IVs and external jugular access would probably be the next “go to options” in these patients. The authors of this paper evaluate yet another option: The Easy IJ. 

April 10, 2017

Background: Ketamine’s role in the ED has expanded in recent years.  The clinical reasons for this make it easy to understand why, and include analgesia, amnesia, and anesthesia. Amazingly, ketamine does not only reduce acute pain, but it also decreases persistent chronic and neuropathic pain as well. More importantly, use of low-dose ketamine (0.1 – 0.3 mg/kg IV) has been demonstrated to be opioid sparing.  Some of the major issues with IV push low-dose ketamine include its adverse effects, such as feelings of unreality, nausea/vomiting, and dizziness. Many emergency medical providers have anecdotally noticed a decrease in adverse effects when ketamine is given slowly. In the paper we are reviewing today, the authors tried to see if increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 - 15 min) could mitigate some of these effects, while maintaining analgesic efficacy.

January 9, 2017

Background: Intraosseous (IO) access can play an important role in the resuscitation of the critically ill patient to help expedite delivery of critical medications (i.e. RSI). Much like with peripheral or central access, obesity can present a challenge to placement of an IO as accurate placement relies on use of landmarks which may not be palpable in this group. Additionally, increased soft tissue depth may render standard needles ineffective. IO needles require 5 mm of excess length from skin to bony cortex to ensure successful placement (i.e. maximal depth of 20 mm for a 25 mm needle). Studies investigating these questions are necessary in order to understand how reliable IO access will be in obese patients.

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