hi! it's great to be here. my name is jonathan ilicki and i'm a physician at the emergency departmentat the karolinska university hospital in solna. this is our resus room, that's how a crash call sounds and that might besome type of patient. hi hi,my name is cliff reid.
[laughter] i'm a helicopter doctorfrom sydney, australia. i just flew here with an ecmo-patientfrom sydney to karolinska in solna, it took me 126 hours and now i feelreally ill. you kind of look like jesper scholander,a physician at our emergency department, but maybe you're a bit confused,so come and lie down here. do you want to drink something?you seem dehydrated. no, the second i drinkanything i just start vomiting
and i have fever of 40.5â°c (105â°f) oh and my neck is stiff,really really stiff, ok i have a headache, and i'm sensitive to the light,can you turn it off? no, i can't. and i can feel that my cerebrospinalfluid has a very low glucose level. ok, anything else?
yeah, my respiratory rate is over 23, and my systolic bloodpressure is under 90. it's bad. i understand, meningitis and sepsis,this is really bad. [internal monologue]: ok,this is really urgent. i'm alone here, so i have to placethe intravenous cannula myself. but i can't find any veins, i guess i could placean intraosseos needle,
but i've never donethat before, it seems difficult, and i don't rememberthe contraindications, and can you really giveantibiotics in an io? yes, you can, it's fine. what, can you hear my thoughts? no, but i can read them. it's very simple: just find the tibial tuberosity,
here's a flat area, justaim for the middle inject some lidocaine, withepinephrine if you want, inject it in the skin anddown by the periosteum. and then drill gently. stop drilling when you get loss-of-resistance, thatmeans the needle has reached the medullary space. and how should i drill? very, very gently not like a construction worker, but like a jeweler:applying gentle consistent pressure.
and what aboutthe contraindications? just think iv cannula any medicine you can give in aperipheral iv you can also give in an io. and just like a normal iv: don't placean io in a wounded or infected area, or distal to a proximal injury. ok, i've got it. i feel really bad, terrible, you have tosave me now!
after that overly dramatic gesturei guess i don't really have a choice. which side should i choose? how convenient! i start by findingthe insertion area find the tibial tuberosity go down to the flat area, and disinfect. lidocaine you might feel this cliff.
ok. and inject lidocaine subcutaneously, and inject a bit moreat the periosteum. [indicates 3 on the vas pain scale] [drill sounds] i will first press down to the bone,and only after i reach the periosteum i will start to drill. and i will drill like a jeweler,not like a construction worker. i'll drill until i get loss-of-resistance,when i've entered the medullary space.
are you still ill? no, i'm unconscious. i push through theskin to the bone, and then i drill. just then, i felt a loss-of-resistance. now we've entered the medullary space,and i want to ensure the io's patency. to show you what happens when you flush,we need some radiological assistance. could you help us and push thebutton that has an arrow beside it? i've heard that's whatradiology is all about.
good, now we have flouroscopy. it's important to flush in order to open up themedullary space and allow rapid infusion. are you with us cliff? aauoe, confused words,not relevant for lecture. ok, let's go. [indicates 10 on the vas pain scale] that woke me up good
how do you feel cliff? jesper. jesper? thank you jonathan, i feel a lot better now, after someantibiotics and fluid resuscitation. oh my, what a day. thank you jonathanfor saving my life. my pleasure. and to all you out there: you can alsosave lives and be heroes by using ios.
just dare to place an iowhen you can't place an iv. it's simpler than you think. contraindications and medication:just think of a peripheral cannula. and dare to do it. even if it's your previous boss that'scome to the ed with meningitis.
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