With the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made much easier. Securing the IO needle to the patient’s tibia, femur, or humerus, however, is a different story. After successful patient resuscitation, these needles often tenuously secured through creative uses of sterile gauze, trimmed paper cups, bag valve masks, and/or just tape. Stabilization of tibial IO lines can be difficult in a sedated, intubated patient. This can be even more difficult in an agitated, moving patient.
In cardiac arrest care it is well accepted that time to defibrillation is closely correlated with survival and outcome.1 There has also been a lot of focus over the years on limiting interruptions in chest compressions during CPR. In fact, this concept has become a major focus of the current AHA Guidelines. Why? Because we know interruptions are bad.2,3 One particular aspect of CPR that has gotten a lot of attention in this regard is the peri-shock period. It has been well established that longer pre- and peri-shock pauses are independently associated with decreased chance of survival.4,5 Can we do better to shock sooner and minimize these pauses?
The Problem: A patient is rolled in to your ED by EMS with extremity trauma. You’re rightfully concerned about possible vascular injury to an upper or lower extremity, but you can’t palpate a dorsalis pedis (DP) or posterior tibialis (PT) pulse! You spend minutes, whisking the doppler probe, attempting to hear a waveform in a busy ED. Unfortunately you can’t seem to hear the “whoosh,” making accurate it nearly impossible for you to measure ankle-brachial indices (ABI). 1–3
So much attention is appropriately focused on the anatomy and technique for intraosseous needle placement. In contrast, very little attention is paid to securing the needle. Often this involves a make-shift setup which involves gauze, wraps, and/or tape. This becomes especially important in the prehospital setting where these can be easily dislodged. The following trick stems from a Twitter discussion in 2015 amongst prehospital providers, lamenting this fact.
Simulation equipment can be rather expensive and wanting to practice fluid and drug administration does not always warrant the purchase of specialized equipment. Luckily, a simple administration trainer can be made in less than 10 minutes and only costs a few dollars (or even nothing). This is an ideal option for resuscitation training if you are already using a manikin without IV arms or an IO option. Learners can practice preparing infusions and administering fluid or preparing an injection and administering it via the syringe port. This trainer can have multiple IV cannulas in one lid and can even include an intraosseous cannula, such as an EZ-IO.
Tranexamic acid (TXA) can be used in a wide variety of settings in the Emergency Department for its hemostatic effects. Topical applications of TXA are commonly utilized to control minor bleeding from epistaxis, lacerations, or dental extractions.1–3 More in-depth reviews of topical TXA can be found on R.E.B.E.L EM4 and The Skeptics Guide to Emergency Medicine.5
Anterior dislocation of the mandible is a clinical scenario that is not infrequently encountered by the ED provider and requires prompt intervention. The classic technique for reduction of the mandible requires the provider to place his/her thumbs or fingers into the patient’s mouth along the lower molars and apply force inferiorly and posteriorly. However, this technique is fraught with difficulties and inefficiencies including the following: