EM Quick Hits 41 – IO Limitations, Missed Ectopic Pregnancy, Bronchiolitis O2 Monitoring, DRE in Cauda Equina Syndrome, Withdrawal of Life Sustaining Care

Topics in this EM Quick Hits podcast

Anand Swaminathan on limitations and practical tips on intraosseus access (0:58)

Tahara Bhate QI corner on missed ectopic pregnancy  (11:38)

Sarah Reid from EM Cases Summit on oxygen saturation monitoring in bronchiolitis and management of infant gastro-esophageal reflux (22:35)

Brit Long on the value of rectal exam in diagnosis of cauda equina syndrome (28:40)

Hans Rosenberg & Ariel Hendin on withdrawal of life-sustaining care in the ED (32:26)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Anand Swaminathan, Michelle Klaiman, Hans Rosenberg, Anna MacDonald & Justin Morgenstern, edited by Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. Klaiman, M. Rosenberg, H. MacDonald A, Morgenstern J. EM Quick Hits 1 - Massive PE, Gabapentin for Alcohol Withdrawal, Dental Avulsions, Pediatric Eye Exam, Best Resuscitation Fluid. Emergency Medicine Cases. January, 2019. https://emergencymedicinecases.com/em-quick-hits-january-2019/. Accessed May 30, 2024.

Intraosseous (IO) access limitations and tips

Limitations of IO access include:

Placing an IO in a bone with a proximal fracture, a previous IO placement attempt or any circulatory compromise proximal to the site is contraindicated

Blood work drawn from an IO are genrally not accurate, so once the patient has been resuscitated with the IO, intravenous blood draws are recommended

Dislodgement is common; it is best to use the stabilizer that comes with the IO kit; if the kit does not have a stabilizer, stack lots of gauze on both sides of the IO needle and tape it down

IOs are only suitable for term infants > 3kg weight; avoid IOs in premies

Best site for IO?

* While proximal humerus site portents faster infusion rates than proximal tibia site, the main limitation of the proximal humerus site is that the arm must be held in internal rotation to avoid dislodgement of the IO

* Proximal tibia may be easier to landmark than proximal humerus

* Other sites include distal tibia, distal femur and sternum but are uncommonly employed in EDs

Needle size?

There are 3 weight-based IO needle sizes, but most experts prefer to choose the needle based on the estimated distance from skin to bone (ie amount of soft tissue)

It is better to overestimate than to underestimate the needle size based on distance from skin to bone

https://www.youtube.com/watch?v=KHXSfh2ZRDM

Expand to view reference list

Sá RA, Melo CL, Dantas RB, Delfim LV. Vascular access through the intraosseous route in pediatric emergencies. Rev Bras Ter Intensiva. 2012 Dec;24(4):407-14.

* Luck, R. Haines, C. & Mull, C. (2010). Intraosseous Access. The Journal of Emergency Medicine. 39(4), 468-475.

* Ngo, A. et.al. (2009). Intraosseous vascular access in adults using the EZ-IO in an emergency department. International Journal of Emergency Medicine. 2, 155-160.

Missed ectopic pregnancy

* Ectopic pregnancy presents with the classic triad of pain, amenorrhea, and vaginal bleeding only about 50% of the time

* There is no combination of history, physical and blood work that definitively rules out ectopic pregnancy...