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Sun Mar 18 23:44:07 GMT 2007

Well, yes, except that an external jugular line is a very different beast
from an internal and in my view only a "get you out of jail" access, the low
approach directly into the innominate is VERY close to aortic
arch/subclavian as you acknowledge as well as pleura and I have never seen
anyone insert an IJ successfully without rotating the head. Glad you can!

-----Original Message-----
From: Ian Seppelt [mailto:SeppelI at wahs.nsw.gov.au] 
Sent: 18 March 2007 23:29
To: rowley at emergencyunit.com
Subject: RE: IO's?...good for?

I never rotate the head before inserting jugular lines, and have done them
prehospital in similar circumstances to those you describe. You don't need
to go head down if you know your anatomy and the patient isn't profoundly
hypovolaemic. Simplest approach of course is the external jugular if you can
see it. Second simplest in this case would be directly into the innominate
vein - bisect the angle between clavicle and clavicular head of the
sternomastoid, feel the subclavian artery and you are in [but dangerous if
you can't feel the subclavian artery passing over the first rib].

I'm not criticising the intraosseous per se - just trying to get my head
around something I'm never had the need to use!

Cheers, Ian

>>> trauma at emergencyunit.com 19/03/2007 10:20am >>>
I'd be delighted to see how one inserts a jugular line without rotating the
head. Remember, this is in the field, not hospital. Whilst I am very much
aged enough to insert jugular lines without ultrasound it is a challenging
procedure if you can't manipulate, put head down etc and don't know what
state the neck is in. 

A saphenous line may have been an alternative in the second patient except I
wasn't anticipating complete failure of the IO. By the time we had some
round the loop of lidocaine - holler - lidocaine three times the car had
been lifted off him and we could get conventional access.

-----Original Message-----
From: Ian Seppelt [mailto:SeppelI at wahs.nsw.gov.au] 
Sent: 18 March 2007 22:54
To: trauma at emergencyunit.com; 'Trauma &amp; Critical Care mailing list'
Subject: RE: IO's?...good for?

In the two examples quoted I'm just wondering why a jugular line was not
possible in the first [trapped with only head and shoulders accessible] and
a saphenous vein was not possible in the second [trapped with only pelvis
and legs accessible]. I'm still trying to imagine the circumstances when
someone comfortable with a range of approaches to veins would want to use
one of these gizmos.

Cheers, Ian

>>> trauma at emergencyunit.com 17/03/2007 7:09am >>>
No offence taken :-) I believe so - I am practised and comfortable with the
technique and am an instructor. The cannula was firmly held in the bone. At
present I'm prepared to write it off as a bad experience (for both of
us)
and it hasn't put me off trying again. It's fairly rare for me to be using
IO as I am comfortable with advanced vascular access, but it most certainly
has its place.

Blueflightmedic.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]

On Behalf Of Andrew J Bowman
Sent: 16 March 2007 20:52
To: Trauma &amp; Critical Care mailing list
Subject: Re: IO's?...good for?

Not to question your skills, but was the IO in the correct spot? Meaning,
were you trying to infuse outside of the medullary cavity and the resulting
infiltrate was causing pain?  I have never seen a properly located IO cause
this much discomfort.

Andrew

----- Original Message ----- 
From: <trauma at emergencyunit.com>
To: "'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
Sent: Friday, March 16, 2007 2:48 PM
Subject: RE: IO's?...good for?

Pain - I simply couldn't get rid of it.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]

On Behalf Of Andrew J Bowman
Sent: 16 March 2007 20:30
To: Trauma &amp; Critical Care mailing list
Subject: Re: IO's?...good for?

What was the problem with not able to infuse? Too much pain or no flow?

Andrew

I drilled a tibia which made him squeak a bit, but
what I was UNABLE to do was put anything through it. You are supposed to put
2 ml of lidocaine through to anaesthetise the medulla but no amount of
lidocaine made any difference (2ml at a time) rendering the IO useless.

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IO's?...good for?