Airway Classics – A Love Supreme?

Many people are eagerly awaiting the release of the new Difficult Airway Society UK (DAS UK) guidelines, in the wake of their recent Annual Scientific Meeting.

Some recommendations are available HERE and include :

  • acceptance of gentle mask ventilation during RSI
  • use of videolaryngoscopy as an option in initial intubation plan
  • apnoeic diffusion oxygenation
  • didactic technique and training for emergency surgical airway

One other recommendation caught my eye – namely to use second generation LMAs

Now the Classic LMA (cLMA) was the brainchild of Archie Brain; it is a wonderful device and has been in commercial use since 1987. It is easy to use and affords the ability to ventilate – although does not protect the airway. Some critics would argue that the LMA has deskilled a generation of anaesthetists, who may use the cLMA for routine cases rather than bag-mask or intubate. I disagree – it is just another tool in the armamentarium.


LMA Classic - cLMA
LMA Classic – cLMA


However I made a decision a few years ago to switch to the Supreme LMA – a lovely second generation LMA that is a step up form the ‘initial’ second generation LMA (the ProSeal). The Supreme combines an integral bite block with a gastric drainage channel in the tip, unlike the ProSeal.

Supreme LMA - sLMA Note gastric drainage channel at tip of cuff
Supreme LMA – sLMA
Note gastric drainage channel at tip of the LMA bowl (R)

But there is a problem – once in place, it is almost impossible to pass an ETT tube through the Supreme.

Many people will be familiar with the Intubating LMA (iLMA) – the brand most use ins the FastTrach. It’s not a bad device – it allows blind intubation rates of up to 90%, using the LMA as a rescue ventilation device and then as conduit for an ETT.

FastTrach Intubating LMA - iLMA
FastTrach Intubating LMA – iLMA

The large handle on the device is designed to facilitate manoevuring of the iLMA in the oropharynx, ideally allowing the bowl of the LMA to align with the glottic opening and hence allow blind passage of an ETT. There is a great paper from the originator of these maneouvres, Chandy Verghese. A description is available HERE – anyone using the FastTrach should be able to perform the “Chandy Manouevre(s)

I like the FastTrach – it is a good ‘go to’ device for rural and remote doctors as allows both rescue ventilation and possible intubation – no pissing around with fancy fibreoptics or calling for help – none is available in the bush! However there are some problems – it’s expensive and it doesn’t have a gastric drainage channel. Furthermore, one can get into a world of hurt if attempting to remove the iLMA over the ETT per instructions. This might include stripping off the pilot cuff of the ETT or ‘losing the airway’…one should read the infamous ‘exploding scrotum‘ case for a masterclass in airway catastrophe.

So problems with the FastTrach are not uncommon in inexperienced hands – precisely the time when you least want to have an additional problem after failed intubation. My advice? Once in, leave both iLMA and ETT in situ until the patient is either awake or you are somewhere with backup!

Furthermore, the FastTrach has a somewhat hyperacute angle, meaning that even if you have a basic fibreoptic device (such as a malleable FO stylet), this cannot be used to turn blind intubation into fibreoptic intubation via the iLMA conduit.

What we need is a device combining the benefits of a second generation LMA (eg Supreme) with an intubating LMA. Enter the second generation iLMA, the AirQ-II

I first heard of these in 2011 from James duCanto in the States. They’ve also had some coverage from Scott Weingart over at EM-Crit in the past. It’s basically a second generation iLMA which is :

  • cheap
  • useful as a rescue ventilation device ie 2nd generation LMA
  • able to be used as an intubating LMA for blind intubation
  • less acute curvature of the tube will allow passage of both flexible and malleable stylet fibreoptics, for visual intubation
  • integral bite block and gastric drainage channel
The AirQ-II iLMA with separate orogastric tube
The AirQ-II iLMA with separate orogastric tube


An elevation bar helps direct ETT tip from bowl of LMA into trachea. The orgastric tube is passed down separate channel adjacent and under the bowl of LMA, into the oesophagus
An elevation bar directs ETT tip from bowl of LMA into trachea. The orogastric tube (left) is passed down separate channel adjacent and behind the bowl of LMA, into the oesophagus

I’ve replaced the FastTrachs with Air-Q IIs in both my RERN prehospital pack and also on our hospital difficult airway trolley. Indeed, for the finance-limited environment of a small rural hospital, the combination of the AIrQ-II along with a fibreoptic device such as a Levitan FPS scope offers a fairly robust option for difficult intubation – drop in an AirQ-II, then wither blindly intubate or use the malleable fibreoptic stylet to pass the tube under direct vision. Then leave the ETT-LMA in site and pop down an orogastric (difficult to do with the FastTrach). James DuCanto writes well on this with a simple guide and Weingart explains how to mould a malleable stylet to conform to the AirQ anatomy.

If you don’t need an intubating LMA, then follow the guidance of DAS2015 and go with a second generation supraglottic device – like the Supreme.

But if you want to allow maximum flexibility including integral intubating-LMA capability, it’s hard to beat the Cook Gas AirQ-II – especially of trying to put together an affordable yet robust difficult airway kit for rural/remote.


RAGE podcast – great FOAMed

I just have to give a shout out to the RAGE PODCAST this week. If you have been living under a rock, the RAGE podcast is a semi-regular “resuscitationists awesome guide to everything” featuring top quality FOAMed contributers who are credible in their field.

“Do not go gentle into that good night

Rage, rage against the dying of the light

Dylan Thomas

This months session is entitle neuroRAGE and deals with all things to do with neurosurgical emergencies. It features Mark Wilson who speaks authentically on experiences as a HEMS physician, neurosurgeon and with some significant anaesthetic experience. I managed to talk with Mark on “Burr holes in the bush” a couple of years ago and since then the idea of prehospital Burr holes has been enthusiastically mooted elsewhere. Is this something that a prehospital service clinician needs to be able to do? Is an extradural the ‘tension pneumothorax of the skull?

Mark gives good talks (if you saw him at smaccGOLD and were impressed, the good news is that he’s back at smaccUS). He’s also prepared to share – he gave a great talk at medSTAR clinical governance day earlier this month and was a major contributor to Sydney HEMS themed neurotrauma session earlier this year – content from the latter is available online. He also runs the AcuteBrain website and is a coninventor of the GoodSAMApp


Also on RAGE, Cliff Reid also gives a lovely description of being on the end of both an LP and in the K-hole, reinforcing the need for concomitant benzos and (where possible) a calm, low stimulus environment to avoid emergence phenomena.

I’ve certainly noticed similar tales of spiral ‘helter skelter’ sensations amongst my dissociated patients…to me this emphasises the need to be familiar with ketamine for both induction, dissociation and analgesia – something all trainees should endeavour to gain experience with in their anaesthetic placements or in ED.

Here’s a video of the potential nasty dissociative effects of ketamine – I love the drug, but consider adding some benzo if appropriate

Anyhow – trust me on this – LISTEN TO THE neuroRAGE podcast. It’s a good one!



It’s gonna be smaccTASTIC! #smaccUS

After months of planning from the smaccTEAM, the programme for smaccUS is now released and available on the smacc website
The program looks HOT – some old favourites and some new allsorts. The genius that is Mark Wilson will be cohosting a fabulous “it’s a Knockout” neurotrauma session….and there are many concurrent sessions and “cage matches” on topical issues.
Plus there’s an excellent round of pre-conference workshops and a chaotic but entertaining social calendar; I am already looking forward to catching up with old friends and making new ones – all united by a common interest in critical illness, from a variety of perspectives (intensivist, emergency, rural, prehospital, medical, nursing, paramedic, social worker etc)
Chicago is a great venue and the first time smacc has ventured overseas. If you missed macc2013 in Sydney and smaccGOLD in 2014 and are wondering what makes this conference different, check out the commentaries at :
…or the smaccVIDEOS from intensivecarenetwork & affiliated sites :
I am delighted to be sandwiched in a session with EM giant Joe Lex, Scandanavian powerhouse from ScanCrit Thomas Dolven and my old mate from BroomeDocs, Casey Parker – all under the watchful eye of Minh le Cong.
Screen Shot 2014-10-29 at 1.54.16 pm
Needless to say I have started preparation on my talk already; I owe inspiration to Penny Wilson (@nomadicGP) for the kernel of an idea which may take fruit at #smaccUS. One should always aim to deliver a memorable talk, so I am learning from the example of an unforgettable talk as made infamous by Prof Brindley
Prepare for your corn to be grilled…

Keeping it all together…

Like most clinicians, my time spent in anaesthesia drilled me in the importance of performing routine pre-anaesthetic machine checks, of keeping the workspace tidy and paying meticulous attention to detail. ‘

These lessons translate well into other areas of practice – at the start of every on call period in emergency, I check the resus trolley and store boxes to ensure we have the right kit available. In recent times I’ve begun to think more and more about resus room ‘feng shui’ – the concept of making sure that the components of the room are ordered correctly, eg :

  • resus & airway trolley on the intubator’s right side so as not to impede visual axis during intubation
  • all monitoring/O2/suction cables & tubes running from single point, allowing almost complete 360 degree access
  • orientation of bed so that clinicians can see monitors, clocks, whiteboard, equipment etc
  • colour-coding of equipment so as to group kit together for those unfamiliar with set up or in a crisis
  • clear signage to essentials such as defib, difficult airway trolley, paediatric kit etc

Working with MedSTAR retrieval builds on this and I get to indulge by obsessive compulsive disorder (it’s called OCD, but aficionados know that it should be called CDO – you…have…to get…letters…in…right order).

Every day starts off with a full kit check (using a challenge-response checklist), then kit tagged and labelled – anything with a broken seal gets a full re-check. Packs are colour coded to aid recall in a crisis (it’s easy to ask a firefighter to get the ‘small red pack sitting in the big blue pack’ rather than tell ‘em to get the arterial line kit). MedSTAR uses an RSI kit dump plastic bag that doubles as a clinical waste repository, with an integral challenge-response checklist.

One of the two-person team (typically doctor-nurse or doctor-paramedic) carries a drug pouch with Schedule 8 drugs (fentanyl, ketamine etc). The team always carry pagers, GRN radio and an iPhone (the latter contains checklists for daily kit checks, contact numbers and SOPs).

In recent times an iPad Mini has become available as an option – although no good as a communication device (unless use FaceTime or Skype!), it is easier to use for performing checklists and reading SOP PDFs. It also allows for addition of useful clinical apps such as Matt & Mike’s excellent Bedside Ultrasound iBook and pre-loading with FOAMed content (podcasts, vodcasts etc). The problem though had been where to carry it – the iPad mini JUST fits into a pocket on the flight suit. Stuffing it into a pack means you’re never likely to use it – it’ll be stored in the back of ambulance, tied down in flight or otherwise inaccessible.

How am I gonna keep my shit together on a cramped helicopter?
How am I gonna keep my shit together on a cramped helicopter?

Despite initial scepticism, I have been using Twitter for the past 18 months to connect with #FOAMed enthusiasts – it’s a great tool for signposting and sharing information from likeminded people around the world, some of whom I have met, some not. Retrieval clinician Natasha Burley (@skimightythings) put out a tweet of the GridIt system in use with Careflight, Queensland a few weeks ago…a sensible idea so good that I had to try it!

So for the past few shifts I have been experimenting with the GridIt system. This is basically a neoprene sleeve and folder for phones, phablets, tablets and PCs, with a series of interlocking bands forming a grid into which chargers, connectors etc can be placed. It’s marketed to power users who carry lots of kit. I find it quite useful for giving presentations as I can make sure I’ve got my projector controller, VGA/HDMI adaptors, power cords, audio cable and other sundries available when giving a talk off home ground.

The Grid It system from cocoon
The Grid It system from cocoon


 The question is as to whether it would ‘value add’ for the retrieval setting. I managed to snaffle an iPad Mini GridIt pouch (had to hunt for the MedSTAR red version on eBay) and experiment with it during a typical shift.

Dan Martin with GridIT
Retrieval Nurse Dan Martin with the Grid IT in our storeroom

I was pleasantly surprised. The neoprene pouch is easy to carry and non-slip despite the recent hot weather (temperatures in the 30s). The iPad Mini fits snugly in the pouch and is further protected by a fold over sleeve. Having the iPad Mini available at all times (rather like the President of the United States ‘football’ of nuclear access codes) meant that I was more inclined to actually USE the device for kit checks and SOPs, as well as afford the potential for mini-tutes on ultrasound and listening to podcasts from my FOAMed mates (eagerly awaiting Mark Wilson & co with neuro edition of RAGE podcast). Listening to content or refreshing knowledge is always possible on the outward leg of a mission, whether by road, rotary or fixed wing.

IPad Mini sits snugly in neoprene puch with GridIt on one side. A neoprene sleeve is folded over the entire assemblage, covering the syringes & iShiny from accidental knocks
IPad Mini sits snugly in neoprene puch with GridIt on one side. A neoprene sleeve is folded over the entire assemblage, covering the syringes & iShiny from accidental knocks

We carry our S8s on our person already, but the syringes and caps are kept in our kit, making it impossible to draw up drugs en route unless remember to get the large major drug/IV pack out before travel. By keeping a few syringes, saline and red caps plus vial access cannulae in the pouch, I found that could mix up basics (ketamine, fentanyl) at anytime using the kit on my person. Once pre-drawn, syringes were kept protected by the neoprene sleeve and readily available.

Grid it with predrawns

I did wonder how we would go in transit WITH a patient, especially in the crowded space of a helicopter. The photos probably don’t do it justice (lots of vibration!) but I found I could secure the GridIt system to the stretcher using the velcro cuffs – or just stuff the darn thing into a pocket if I was worried.

Depending on the aircraft and configuration with stretcher, I found could secure to either the side of the stretcher so that iPad and drugs were within easy reach (basically between legs if sitting side on to stretcher)…or secure to the head end where we already stash bag-valve-mask in a pouch.

The ability to reverse the neoprene sleeve and loop around the stretcher rail then secure with velcro worked well – but for added security one could easily add a carabiner.

On the outward bound (no patient) I used the GridIt to secure syringes and secured the entire package to stretcher rail by looping the neoprene sleeve around rail and velcroing. One could add a loop for carabiner easily.
On the return leg – iPad and drugs secured to stretcher side for easy access in flight
Hanging the iPad Mini and predrawn syringes off the head end of stretcher (head elevated in this picture) – means both FOAMed and DRUGS available immediately!

We already have a system of securing pre-drawn syringes (for bolus dosing) on a hoop system on our ventilator. Many missions don’t require a ventilator, just standard monitoring, so the options have usually been to stuff syringes into a pocket on flight suit.

Adding an iPad to the mix means pockets get full or tend to either stash in a pack bag (inaccessible) or just leave the thing behind… a shame as having an iPad available could value add to missions, I feel.

Combining the iPad Mini and syringes in one system seemed to work well. I am interested in other options available out there!

Spotted in the UK and tweeted by my mate Dr Alan Grayson (of the StEmlyns blog crew) - not sure this will catch on; nor is there space for iPad!
Spotted in the UK and tweeted out to the world by my mate Dr Alan Grayson (of the StEmlyns blog crew) – not sure this bandolier approach will catch on; nor is there space for an iPad!

And what else should we put on the ipad Mini?

The next question will be which apps and FOAMed content should be included on a tablet. MedSTAR has it’s own proprietary app for checklists and SOPs. My preference would be to add :

[ I am a big fan of the UK HEMS SOPs available online - and the Sydney HEMS clinical governance and sim resources in particular - ]

Who knows? Perhaps in the future my mate Mark Wilson’s GoodSAMapp could be added to not just individual clinicians smartphones, but also to institutional devices – as it allows tracking of location and ‘push’ alerts integrated with comms CAD; potentially very useful in a MAJAX situation

GoodSAM app for smartphone (iOS and Android, Windows etc) - not just for first responder BLS, but also to track and push info to institutional members via central ambulance dispatch
GoodSAM app for smartphone (iOS and Android, Windows etc) – not just for first responder BLS, but also to track and push info to institutional members via central ambulance dispatch


Hey! If you are a Paramedic, Nurse, Doctor or Registered First Aider who can hold open an airway or do BLS, please take time to register with GoodSAMapp for Android or iOSIt’s FREE



CPD points for #FOAMed & SoMe?

Tapping into the collective wisdom of tacit knowledge sharing and asynchronous learning via the #FOAMed community has markedly changed the way I practice. A few years ago, I would jump through the necessary hoops of continuing professional development (CPD) or personal development programmes (PDP) with my College. To be honest, as a rural proceduralist, it was relatively easy to accrue points and meet the necessary number required each triennium (three year cycle).

But the reality is that these points were met by doing the minimum necessary standard ie attending a few of the alphabet courses like EMST/APLS/REST, attending an annual conference, perhaps attending a workshop or local educational session, usually delivered by a metrocentric specialist. Within a year or so I had accrued enough points for the three-yearly triennial cycle. I am sure that there was some learning at these events – but I was not being stretched. Which is kind of odd. It seems that the educational focus of the Colleges is more about training registrars, but not necessarily about ongoing training of Fellows, other than to ensure that a minimum standard is met.

So the involvement in the FOAMed world re-ignited my passion for learning … and for teaching. I wont re-hash the concept of FOAMed here – it’s well-described elsewhere – suffice it to say, it allows asynchronous leaning, tacit knowledge sharing amongst peers and is ideal for discussing mastery or finesse in the craft, rather than the minimum educational requirements or becoming a slave to protocols and guidelines which are not necessarily applicable to the individual patient in front of us (90 yos on statins anyone?).

I started off by reading blogs from fellow rural doctors…then dipping my toes into making a few tentative comments on hypothetical case discussions…then creating my own content to reflect on own activities and perhaps help educate others…then build on this via content creation, collation, curation and communication.

Dipping in and out of FOAMed is another mode of learning, useful for finesse, with ability to access the global medical community hive mind for information.

FOAMed – free, open access medical education – anywhere, anyplace, anytime

But there is a problem with FOAMed or indeed any learning that occurs via social media interactions – this form of learning is not recognised, despite the fact that it offers a more advanced and self-reflective adult learning style (in fact FOAMed moves one into understanding HOW to learn (the concept of heutagogy). Different media – video vodcasts, audio podcasts, links to reevant papers, online discussion fora and ability to interact both online and offline allow asynchronous learning. Moreover this learning is not constrained by geography – interactions occur with colleagues globally – and as if that wasn’t enough, traditional silos break down – I find myself discussing aspects of care with not just fellow rural proceduralists, but with specialists, with academics, with social workers, with paramedics, with students. It’s a true meritocracy.

There was some recent chatter on GPSDownUnder (a closed facebook community) about the concept of accruing CPD points for this sort of activity, with no real answers (although over 154 comments). Interestingly other online platforms (notably the UK’s online community of over 200,000 doctors, Doctors.Net.UK allows accumulation of points for engaging in online debate, and is recognised in the UK’s revalidation programme. I have no doubt that revalidation will, in some form, be imposed on us in Australia – and reflective practice is part of this.

Those who are already active in FOAMed are not just users of content, but are interested in creating it. It would be good to get points for this sort of activity. Of course the irony is that these people already have accrued sufficient points for the triennium and are engaged purely for the love of learning and desire to be ‘better’. To make this sort of learning attractive to others, it needs to have a demonstrable advantage over existing modes of learning. For me the hook is that FOAMed allows me to refine my practice through tacit knowledge sharing and develop finesse….to engage in ‘corridor conversations; with colleagues worldwide and allow me benefit from decades of experience to apply to the patient in front of me, not just blindly follow a guideline. it’s about art as well as science!


What better way to meet requirements than to seek true mastery and finesse in one’s craft, with reflection, by use FOAMed and SoMe?

So I was thrilled to be invited to a breakfast meeting with RACGP educational reps and fellow GP bloggers/twitterati, Drs Karen Price, Ewen McPhee & Tim Senior.

Dr Ewen McPhee, Dr Tim Senior. Dr Tim Leeuwenburg. Ms Helen Barry (RACGP) & Dr Karen Price [photo by Dr Marlene Pearce]
It is clear that having a College control content is contrary to the ethos of free-flowing and cutting edge FOAMed.

We decided that a useful framework for accreditation (ie : collection of points for CPD/PDP activities online) needed to embrace the following concepts

(i) define principles of what is/what is not relevant educational activity

At the minimum, recognition of an activity for points should require that the activity is relevant to practice (might be across domains of clinical, practice admin, ethical etc), requires a degree of interactivity and a degree of reflection

(ii) create a tool to log activity

People have talked about ‘endorsing’ websites or activities, or using loggers to demonstrate time spent in an activity. However as adult learners this is too constraining. there are existing templates (we use one in ACRRM for logging of clinical attachment activities) which would suffice.

Such a template should encompass

  • the nature of activity (eg: reading blog, listening to podcast) and the learning objectives thereof,
  • a comment on specific learning outcomes
  • encouraging comment (reflective practice) on how this is relevant to one’s practice and
  • the documentation of these, with supporting evidence if appropriate (eg: screenshot of comments page, link to content etc)

Having a form either online or easily downloadable would allow clinicians to document learning activities outwith the usual College program and apply for points.

Ultimately it is up to the user to define his/her learning and also to be able to defend their activity in case of audit. There is concern of ‘gaming’ the system – I would argue that this happens already, with many educational activities being low quality and gamed to some degree. Negative feedback on low quality educational activity is not always forthcoming, due to the inherent conflict of attendees not wanting to jeopardise their own points by feeding back that an event was crap! Better to accrue the points and move on…

(iii) signpost relevant content to target audience

Each College (ACRRM, RACGP) already has regular newsletters. Using a panel of SoMe and FOAMed enlightened primary care physicians, it would be very easy to collate a regular (fortnightly or monthly) round up of relevant and interesting FOAMed content – the EM crew at have been doing this every week for a few years now via their LITFL review. this is a wonderful way to signpost content to clinicians, leading to more interactivity and acceleration of the learning paradigm.

Docere – to teach – innit?

So – there you have it. A proposal for recognition of online FOAMed learning for primary care physicians in Australasia. Start off with links to interesting FOAMed material, disseminated through the Colleges. As time goes on, encourage clinicians to accrue points via interaction in this space. And hopefully such interaction will create more connectivity and community, as well as more content creation.

It would be awesome if both ACRRM and RACGP got on board with this – as this is the space where true learning is occurring. Too often medical education is either about the basics required for Fellowship and the maintenance of a minimum standard, with most research focussed on GP training pathways or recruitment/retention.

I would argue that we should be working together on the finesse to achieve mastery…always seeking to be better.

What do YOU think?




Is the IO really dead?

I was unable to attend the annual Australian Trauma Society meeting this year (truth be told, my membership lapsed and I’ve been busy with other projects recently). But in these days of FOAMed and use of social media to connect, I was able to follow vicariously via the twitter feed from #Austrauma. One tweet, admittedly not direct from the Austrauma feed, but from one of it’s speakers – caught my eye.

Screen Shot 2014-10-05 at 1.31.42 pm

Now it’s hard to argue with Karim Brohi – if you’ve not met him, he’s the chap who kicked off perhaps one of the earliest ever FOAMed sites – the thoroughly excellent site (which turns 20 years old in 2015!). He’s well-regarded as a trauma expert, international speaker and leading trauma researcher. He’s also a nice chap and interacts with others through the twittersphere – whether trauma guru, student, rural doc or paramedic. I reckon he’s a chap who believes in striving for quality improvement across the board – his words from smaccGOLD still resonate re : use of audit to improve systems and lead to innovation, such as implementation of REBOA “you have to sweep the floor, everyday

So I was surprised by this statement from Brohi regarding the demise of the IO. Use of IO has taken some time to percolate down; I remember as a junior reg (so maybe 10 years ago) being admonished for placing an IO in a shut down 14 year old s they were “only to be used in children 9 years and under”. Nowadays there is no age limit – and we’ve moved from the old fashioned Cooks IO device to alternative device, the use which is taught in APLS, ATLS and other entry-level courses. Heck, we’ve even (finally) got them into small rural hospitals here in Oz!

I think Karim was purely referring to the utility of IO in a tertiary level resus bay, where rapid administration of blood is needed – the need to use pressure to infuse can cause to cell lysis, negating any advantage.

So is the IO route really dead?

I think not. Imagine a patient entrapped. Access through the window allows access to the humeral head and placement of an IO to facilitate extrication via administration of agents such as ketamine. In a resus bay, placement of an IO allows early administration of fluid and drugs, for both analgesia & procedures such as RSI.


Sure there are other routes – intranasal, intramuscular, rectal….and I’ve even placed an IV in the corpora cavernosa once (well, it communicates with the vascular space – just don;t run an adrenaline infusion through a line placed in the willy)

Placement of a subclavian swan sheath or peripheral rapid infuser catheter is ideal if rapid administration of warmed fluids is needed. Indeed I think RICs should be available not just in resus, but anywhere where people bleed – theatre, labour ward and prehospital.

Here’s the infamous ‘AC/DC & Barry White rapid infuser mashup’, which Scott Weingart chose for inclusion in Roberts & Hedges Emergency Procedures in Emegrency Medicine  as a video demo of how to place a RIC…

We still teach venous cutdown on ATLS in the animal lab – although the last cutdown I saw was over a decade a go in a difficult ED resus, requiring attempts at both saphenous and brachiocephalic veins.

Options for IO devices?

There are a few devices out there. Access points include humeral head, proximal & distal tibia, ischial crest and sternum (the latter is for FAST-1 only, not EZ-IO or BIG).

IOs such as the EZ-IO reportedly allow rates of 125ml/min, with the intrasternal device (mostly used in military) quicker still. remember to WARM FLUIDS so as not to contribute to the lethal triad.

Lethal triad

YouTube always seem to have some videos of these devices being put in – I admit that I’ve had an EZ-IO put in, which I didn’t find at all painful (and I am a bit of a needlephobe). However having 10ml of saline pushed through the device hurt big time! Some recommend administration of 1-2 ml of lignocaine prior to running in fluid (remember to use a pressure bag or dedicated person using three-way tap). Still hurts like a MoFo though!

Old fashioned Cook IO needle – these are now mostly gathering dust in the corner of EDs or have been removed completely. They were the device that we trained with on APLS a decade ago. Sadly it was relatively easy to push through the bone – and into the palm of your hand if supportng the childs lower limb.

The Bone Injection Gun – a spring-loaded IO device, which is designed for ease of use. Our hospital purchased these (no consultation with clinicians) and I can report that the experience has been disappointing. despite training, we have had nurses sustain sharps injuries by deploying the wrong way around. Locums unfamiliar with the device have struggled. One of the major problems is that the recoil of the spring can be taken up by the hand-forearm unless wrist is “cocked and locked”. Of course there is no tactile feedback either.

Although much cheaper than the EZ-IO device, the fact that failure rate is both means that 2-3 may be used per insertion attempt (anecdotal data from local experience), I would avoid the BIG, and instead recommend…

The EZ-IO device – this is simple to use. Sadly the drills are crazy expensive, as are the needles – however they allow easy insertion, give tactile feedback and are the device with which most clinicians train, making them the sensible choice. I ended up doing a deal with the health department, whereby purchased my own drill for prehospital and ED use, with needles being supplied by the Health Department.

And lastly, the FAST-1 device – this is an intra-sternal device favoured by the military (which kind of makes sense in combat as victims limbs may be blown off)

You can read a review of these devices HERE

Intraosseous Devices for Intravascular Access in Adult Trauma Patients Day M.W. (2011) Crit Care Nursing 2011 31 : 76-90 doi: 10.4037/ccn2011615 

“It’s blood they bleed, so it’s blood they need”


For now, I will be keeping my EZ-IO handy – I appreciate it’s not brilliant for rapid administration of fluids inc blood, but the ease of use and ability to rapidly administer analgesia or sedation/RSI drugs makes it a useful tool in the armamentarium…

…and if all else fails, there’s always a 14G needle and a strong arm to gain IO access!