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Intraosseous Vascular Access

The Worldwide Clinical Need. Need for Vascular Access. Study by large national EMS service found that 20% of level 3 transports arrived in the ED without an IVThis data confirmed by independent survey of several large urban EMS servicesTime spent trying to start difficult IV's in the field delays patient transport and distracts the medic from clinical decision making .

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Intraosseous Vascular Access

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    1. Intraosseous Vascular Access

    2. The Worldwide Clinical Need

    3. Need for Vascular Access Study by large national EMS service found that 20% of level 3 transports arrived in the ED without an IV This data confirmed by independent survey of several large urban EMS services Time spent trying to start difficult IV’s in the field delays patient transport and distracts the medic from clinical decision making

    4. History of intraosseous access IO has endured for more than 65 years as a safe and effective alternative to IV Reports of over 4,000 adult patients treated during the 1940’s and 50’s Established standard of care in Pediatric Advanced Life Support Recently adopted standard of care in American Heart Association and European Resuscitation Council guideline revisions

    5. AHA, ERC, ILCOR, NAEMSP Guidelines IO should be considered early in vascular access emergencies Adults - 2 peripheral IV attempts Progress to IO Pediatrics - 1st line of choice ET tube is no longer recommended for drug delivery Central lines are discouraged Approximately 5 million central venous catheters placed each year in US Central line placement causes unnecessary drug delivery delay during resuscitation CDC report indicates 9% infection rate with central lines in US

    6. Central Line Infections Central venous catheter-related infection in a prospective and observational study of 2,595 catheters Critical Care 2005, 9:R631-R635  ICU study of 2,018 patients in Spain. Central line infection rates

    7. Central Line Costs CRBSI adds $25,000 to $50,000 in costs Increased length of stay More time in ICU Expensive antibiotics Internal jugular and subclavian catheters require a chest x-ray Chest compressions must be halted for subclavian placement Time spent placing CVC distracts and delays physician from resuscitation decision making

    10. Pressure and Flow Rates With pressure, IO flow rates are similar to IV Tibial relates to a 18 gauge catheter Humeral relates to a 16 gauge catheter Flow rates for infusions given through an IO with a 300 mm pressure infuser 3 – 6 liters/hour of saline Unit of blood in approximately 15 - 30 minutes Syringe bolus infusions can be completed in seconds Initial rapid 10 cc syringe bolus dramatically increases IO flow rates

    14. Historic complications for most IO devices Extravasation Compartment syndrome Dislodgement Fracture Failure (Device or user in origin) Pain Infection

    15. Contraindications for IO Fracture Infection at the insertion site Prosthesis Recent IO in same extremity (24 hours) Absence of Anatomical Landmarks (Excessive Tissue)

    16. Research Literature More than 400 articles in peer reviewed journals since 1922 Strong support for the use of IO as a quick, safe and effective alternative to difficult or impossible IV access Over 20 pharmacokinetic studies in animals indicate IO is equal to IV Numerous recent scientific presentations and papers

    17. FDA & CE Cleared IO Devices Jamshidi / Cook Historically used for pediatrics – manually operated FAST - 1 Designed for adult sternum only Inserts 10 needle probes and single IO catheter – manually operated B.I.G. Bone Injection Gun Rapidly projects a needle set – coiled spring EZ-IO Inserts hollow needle set into the medullary space – orthopedic drill

    18. F.A.S.T. 1 by Pyng

    19. BIG (Bone Injection Gun)

    20. EZ-IO by Vidacare

    23. Protocol

    27. IO vs Central Venous Catheter Preliminary data from experiments conducted by Drs Hoskins and Kramer at UTMB show that proximal humerus IO delivery of epinephrine improves arterial pressure at least as much as central venous delivery. Results suggest that Proximal humerus IO delivery is as effective as sternal IO delivery, which also was similar to central venous delivery. Personal Communication, Dr. George Kramer, University of Texas Medical Branch, Galveston, Texas

    29. Prospective 250 Patient Study of EZ-IO Multi-center study involving 16 EMS services 148 male and 102 female adult patients 76% medical, 24% trauma Results 97% success rate: placement and ability to infuse drugs/fluids Average insertion time of 10 seconds Users (10 EMT-Is, 140 EMT-Ps, 35 LPs, 61 RNs and 4 MDs) reported good control of the device and its function 100% of the time Average pain score in alert patients was 2.5 (on 0 – 10 visual analog scale) Now over 7000 insertions with data consistent with above, including no reported cases of osteomylitis or superficial skin infections

    30. Indications for intraosseous access Altered Level of Consciousness Respiratory Compromise Need for immediate rapid sequence induction Hemodynamic Instability Mass Casualty Situations Trauma Resuscitations Difficult IV Placement Bridge to Central Line Allowing Controlled Placement

    31. Questions

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