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EZ-IO PD Proximal Humeral Access

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EZ-IO PD Proximal Humeral Access

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    1. EZ-IO PD Proximal Humeral Access This Vidacare EZ-IO® PD Proximal Humeral Access Training Program is designed to help you understand and use the EZ-IO® infusion system. Our collective goal at Vidacare® remains rapid, safe, effective vascular access for all critical patients. Vidacare’s approach to this goal is simple – the right equipment - in the best hands – where it’s needed most. Associated with this supplemental program is a complete training system. This includes the Directions For Use (DFU), Quick Reference Card, Insertion/Removal Poster and PowerPoint™ Presentations (“Start up” and “In Depth” versions), Mannequins, Training Driver and Needle Sets, Complete Website with instructor resource center and finally a 24 hour emergency support telephone line. At the completion of this supplemental training program if you still have questions or concerns please call us at 1.866.479.8500 or visit our website at www.vidacare.com We at Vidacare® appreciate what you do and the time you devote to it. Thank you for inviting us to be a member of your team! This Vidacare EZ-IO® PD Proximal Humeral Access Training Program is designed to help you understand and use the EZ-IO® infusion system. Our collective goal at Vidacare® remains rapid, safe, effective vascular access for all critical patients. Vidacare’s approach to this goal is simple – the right equipment - in the best hands – where it’s needed most. Associated with this supplemental program is a complete training system. This includes the Directions For Use (DFU), Quick Reference Card, Insertion/Removal Poster and PowerPoint™ Presentations (“Start up” and “In Depth” versions), Mannequins, Training Driver and Needle Sets, Complete Website with instructor resource center and finally a 24 hour emergency support telephone line. At the completion of this supplemental training program if you still have questions or concerns please call us at 1.866.479.8500 or visit our website at www.vidacare.com We at Vidacare® appreciate what you do and the time you devote to it. Thank you for inviting us to be a member of your team!

    2. Indications for Proximal Humerus Access Altered level of consciousness Respiratory compromise Hemodynamic instability Listed here are the primary indications. Can you think of specific conditions that would fit each indications? Examples of disease states often meeting these criteria include, but are not limited to the following: Cardiac arrest, Status epilepticus, All shock states, Arrythmias, Dehydration Burns, Drug Overdose, DKA (diabetic), Renal failure, Stroke, AMI, Coma, OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema, Respiratory arrest, Hemophiliac crisis Listed here are the primary indications. Can you think of specific conditions that would fit each indications? Examples of disease states often meeting these criteria include, but are not limited to the following: Cardiac arrest, Status epilepticus, All shock states, Arrythmias, Dehydration Burns, Drug Overdose, DKA (diabetic), Renal failure, Stroke, AMI, Coma, OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema, Respiratory arrest, Hemophiliac crisis

    3. Contraindications for Distal Tibial Access Fracture (targeted bone) Previous orthopedic procedures near insertion site (IO within past 24 hours/Prosthetic Limb or joint) Infection at the insertion site Inability to locate landmarks or excessive tissue These are the contraindications. Recent fractures may cause fluid or drugs to leak – thus not reaching target tissue and possibly causing additional significant injury. Certain Orthopedic procedures at or near the insertion site. An example of an orthopedic procedure that would cause problems for the EZ-IO® would be a joint replacement. This would render the IO space inaccessible secondary to the indwelling device. Another example would be a recent (within the past 24 hours) IO placement in the same extremity. This “extra penetration” might allow extravasation (leakage) into surrounding soft tissue from the initial IO site. Not all orthopedic procedures pose a contraindication or concern to EZ-IO® usage. Infections at the insertion site pose a risk because they could be introduced into the bone and systemic circulation. Inability to locate the EZ-IO® landmarks could result in an attempted placement that is unacceptable and dangerous. Lastly, Excessive tissue over the insertion site may result in the needle set failing to reach the intraosseous space. With each of the contraindication listed above the provider should consider alternate appropriate sites. Additionally, a risk versus benefit assessment should always be considered prior to any IO placement. These are the contraindications. Recent fractures may cause fluid or drugs to leak – thus not reaching target tissue and possibly causing additional significant injury. Certain Orthopedic procedures at or near the insertion site. An example of an orthopedic procedure that would cause problems for the EZ-IO® would be a joint replacement. This would render the IO space inaccessible secondary to the indwelling device. Another example would be a recent (within the past 24 hours) IO placement in the same extremity. This “extra penetration” might allow extravasation (leakage) into surrounding soft tissue from the initial IO site. Not all orthopedic procedures pose a contraindication or concern to EZ-IO® usage. Infections at the insertion site pose a risk because they could be introduced into the bone and systemic circulation. Inability to locate the EZ-IO® landmarks could result in an attempted placement that is unacceptable and dangerous. Lastly, Excessive tissue over the insertion site may result in the needle set failing to reach the intraosseous space. With each of the contraindication listed above the provider should consider alternate appropriate sites. Additionally, a risk versus benefit assessment should always be considered prior to any IO placement.

    4. Anytime you are providing care to the public it is important to protect yourself as well as the patient. Practicing proper Body Substance Isolation (BSI) is vital to quality patient care and is recommended anytime the EZ-IO® infusion system is in use. Anytime you are providing care to the public it is important to protect yourself as well as the patient. Practicing proper Body Substance Isolation (BSI) is vital to quality patient care and is recommended anytime the EZ-IO® infusion system is in use.

    5. The important anatomy of the proximal humerus is relatively easy to understand and appreciate* provided that the model or patient is in a supine position (or at a minimum leaning back in their chair - with shoulders against the back rest) - with the arm adducted and the elbow posteriorly located. The important anatomy of the proximal humerus is relatively easy to understand and appreciate* provided that the model or patient is in a supine position (or at a minimum leaning back in their chair - with shoulders against the back rest) - with the arm adducted and the elbow posteriorly located.

    6. To begin the discussion on humeral access we must first position the arm for maximum humeral head exposure. Adduct the humerus then posteriorly locate the elbow toward the back rest of your chair (or floor if you are laying down). Next, place the patient’s hand on the patient’s abdomen – at near the umbilicus. This will provide for a more prominent insertion site as well as ensure protection for the vital neurovascular structures located under the patient’s arm. Important note: By placing the hand on the umbilicus (rather than the entire forearm across the abdomen) you will be able to retain the elbow on the stretcher or the ground and maximize your approach to the humeral head. To begin the discussion on humeral access we must first position the arm for maximum humeral head exposure. Adduct the humerus then posteriorly locate the elbow toward the back rest of your chair (or floor if you are laying down). Next, place the patient’s hand on the patient’s abdomen – at near the umbilicus. This will provide for a more prominent insertion site as well as ensure protection for the vital neurovascular structures located under the patient’s arm. Important note: By placing the hand on the umbilicus (rather than the entire forearm across the abdomen) you will be able to retain the elbow on the stretcher or the ground and maximize your approach to the humeral head.

    7. Preferred insertion site identification method The patient should be in a supine position. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. A Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or humeral head. As you near the shoulder you will note a protrusion. This is the base of the greater tubercle insertion site. A With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself. The patient should be in a supine position. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. A Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or humeral head. As you near the shoulder you will note a protrusion. This is the base of the greater tubercle insertion site. A With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself.

    8. B Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process and the acromion. One can envision the location of this site by creating a “T” - the upper portion of connecting the coracoid process and the acromion while the “point” reaches inferiorly and slightly anteriorly - approximately two finger widths- on the midline of the humerus. B Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process and the acromion. One can envision the location of this site by creating a “T” - the upper portion of connecting the coracoid process and the acromion while the “point” reaches inferiorly and slightly anteriorly - approximately two finger widths- on the midline of the humerus.

    9. The patient should be in a supine position A/B 1. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. Forearm resting on the abdomen (With the patient in this position you may immediately note the humeral head on the anterior-superior aspect of the upper arm or anterior-lateral shoulder) A Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or humeral head. As you near the shoulder you will note a small protrusion. This is the base of the greater tubercle insertion site. With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself. Alternatively: B Identify two land marks on the lateral shoulder consisting of the acromion and the coracoid process. This can be accomplished by placing one hand on the lateral superior aspect of the patient’s shoulder and palpating for the protrusions. Identifying the coracoid process and the acromion can also be accomplished by “walking” your index and middle finger along the clavicle to the shoulder’s lateral end. B Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process and the acromion. One can envision the location of this site by creating a “T” - the upper portion of the letter connecting the coracoid process and the acromion while the “leg” reaches inferiorly and slightly anteriorly - approximately two finger widths along the midline between the two structures. Do not attempt insertion medial to the greater tubercle! The patient should be in a supine position A/B 1. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. Forearm resting on the abdomen (With the patient in this position you may immediately note the humeral head on the anterior-superior aspect of the upper arm or anterior-lateral shoulder) A Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or humeral head. As you near the shoulder you will note a small protrusion. This is the base of the greater tubercle insertion site. With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself. Alternatively: B Identify two land marks on the lateral shoulder consisting of the acromion and the coracoid process. This can be accomplished by placing one hand on the lateral superior aspect of the patient’s shoulder and palpating for the protrusions. Identifying the coracoid process and the acromion can also be accomplished by “walking” your index and middle finger along the clavicle to the shoulder’s lateral end. B Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process and the acromion. One can envision the location of this site by creating a “T” - the upper portion of the letter connecting the coracoid process and the acromion while the “leg” reaches inferiorly and slightly anteriorly - approximately two finger widths along the midline between the two structures. Do not attempt insertion medial to the greater tubercle!

    10. Confirm and clean insertion site Once you have identified the greater tubercle - confirm the specific insertion site by palpation of the greater tubercle’s outer margins ultimately resting your finger on the most prominent aspect of that structure – the EZ-IO® PD insertion site.Once you have identified the greater tubercle - confirm the specific insertion site by palpation of the greater tubercle’s outer margins ultimately resting your finger on the most prominent aspect of that structure – the EZ-IO® PD insertion site.

    11. Insert EZ-IO PD needle set Stabilize the arm and place the powered EZ-IO® PD - maintaining a 90 degree angle during the insertion process. IMPORTANT - Stabilize the needle set prior to any attempt at removing the driver. The Humeral cortex can be considerably “less dense” and failure to stabilize the catheter may cause inadvertent dislodgment. Stabilize the arm and place the powered EZ-IO® PD - maintaining a 90 degree angle during the insertion process. IMPORTANT - Stabilize the needle set prior to any attempt at removing the driver. The Humeral cortex can be considerably “less dense” and failure to stabilize the catheter may cause inadvertent dislodgment.

    12. Remove the stylet and syringe flush catheter Attach the EZ-Connect® extension set to the standard Luer lock & confirm placement of the catheter. This can be accomplished by identifying several important findings: The catheter is firmly seated and does not move. Observed blood on the stylet tip (noted by wiping tip on a 4x4) prior to placing stylet in the shuttle or bio hazard container. You note blood at the catheter hub. You are able to aspirate blood or marrow from the catheter (We recommend aspirating a small amount of blood due to its extremely viscous nature). Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or around the tissue. CAUTION: Conscious patients will experience pain with infusion prior to Lidocaine! Flow rates may be slow or non existent prior to the 10 ml bolus. You note the effects of administered drugs. X-Ray confirmation. Protect the sterile connection point on the catheter hub! Four Important points to consider once the EZ-IO® has been established: Routinely reconfirm that the EZ-IO® catheter is secure and in position. Maintain appropriate protection at the insertion site guarding against accidental bumping or dislodgement. Frequently monitor the EZ-IO®, the fluid and the extremity. Remove the EZ-IO® within 24 hours. Attach the EZ-Connect® extension set to the standard Luer lock & confirm placement of the catheter. This can be accomplished by identifying several important findings: The catheter is firmly seated and does not move. Observed blood on the stylet tip (noted by wiping tip on a 4x4) prior to placing stylet in the shuttle or bio hazard container. You note blood at the catheter hub. You are able to aspirate blood or marrow from the catheter (We recommend aspirating a small amount of blood due to its extremely viscous nature). Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or around the tissue. CAUTION: Conscious patients will experience pain with infusion prior to Lidocaine! Flow rates may be slow or non existent prior to the 10 ml bolus. You note the effects of administered drugs. X-Ray confirmation. Protect the sterile connection point on the catheter hub! Four Important points to consider once the EZ-IO® has been established: Routinely reconfirm that the EZ-IO® catheter is secure and in position. Maintain appropriate protection at the insertion site guarding against accidental bumping or dislodgement. Frequently monitor the EZ-IO®, the fluid and the extremity. Remove the EZ-IO® within 24 hours.

    13. Avoid rocking the EZ-IO catheter during usage Do not connect a syringe directly the EZ-IO® during treatment. Use of the EZ-Connect® will help to avoid complications. Do not connect a syringe directly the EZ-IO® during treatment. Use of the EZ-Connect® will help to avoid complications.

    14. Begin infusion with pressure * If you need a blood sample for lab analysis – we recommend drawing blood directly from the EZ-Connect® with a syringe. Be certain to adequately flush the tubing after the sample is obtained. Prior to any drug or fluid administration be certain to Syringe flush the EZ-IO® catheter with 5 ml of fluid. NOTE: THERE IS A DISTINCT DIFFERENCE BETWEEN THE “SYRINGE FLUSH OR BOLUS” DESCRIBED ABOVE AND FLUID “GIVEN OR PUSHED WITH AN ADMINISTRATION SET”. This difference relates specifically to: The pressures generated by the syringe – clearing the “pathway for treatment” (Which is necessary because of the anatomy and nature of the IO space) Versus the relatively slow, low pressure “supportive administration” of fluids given over time. “NO FLUSH = NO FLOW” Failure to “syringe flush” may result in a limited or no flow IO situation * If the patient is conscious slowly administer 0.5 mg/kg of 2% (Preservative free) Lidocaine IO prior to the initial bolus. IO fluid administration causes pain for conscious patients and is related to intramedullary pressure. Lidocaine has proven to be an extremely effective treatment for this pain. (Utilizing a Lidocaine pre-filled syringe simplifies this process – but must be approved by protocol) Insure that you protect the patient and the sterile connection point on the catheter hub! * If you need a blood sample for lab analysis – we recommend drawing blood directly from the EZ-Connect® with a syringe. Be certain to adequately flush the tubing after the sample is obtained. Prior to any drug or fluid administration be certain to Syringe flush the EZ-IO® catheter with 5 ml of fluid. NOTE: THERE IS A DISTINCT DIFFERENCE BETWEEN THE “SYRINGE FLUSH OR BOLUS” DESCRIBED ABOVE AND FLUID “GIVEN OR PUSHED WITH AN ADMINISTRATION SET”. This difference relates specifically to: The pressures generated by the syringe – clearing the “pathway for treatment” (Which is necessary because of the anatomy and nature of the IO space) Versus the relatively slow, low pressure “supportive administration” of fluids given over time. “NO FLUSH = NO FLOW” Failure to “syringe flush” may result in a limited or no flow IO situation * If the patient is conscious slowly administer 0.5 mg/kg of 2% (Preservative free) Lidocaine IO prior to the initial bolus. IO fluid administration causes pain for conscious patients and is related to intramedullary pressure. Lidocaine has proven to be an extremely effective treatment for this pain. (Utilizing a Lidocaine pre-filled syringe simplifies this process – but must be approved by protocol) Insure that you protect the patient and the sterile connection point on the catheter hub!

    15. To remove the EZ-IO catheter from ANY APPROVED location attach a sterile syringe then rotate slowly clockwise - while gently pulling. The EZ-IO® catheter should be removed within 24 hours! Removal of the EZ-IO® catheter is simple. You may either grasp the hub directly or attach a sterile syringe. (The syringe will serve as a larger handle for the catheter hub and is preferred) Support the patient’s extremity while rotating the catheter clockwise and gently pulling. (Recall that the exterior portion of the catheter is smooth or not threaded). Rotating the hub during removal reduces catheter to bone friction and will allow for an easier removal process. Be careful with the sharp catheter once removed from the patient! Once the catheter has been removed immediately place it in an FDA approved bio hazard sharps container. We recommend that you place a portable sharps container near the patient for this procedure (example - P2 Sharps Shuttle by Tyco/Kendall) Removal of the extension or fluid administration set, without proper protection of the EZ-IO® hub (in the form of a sterile cap, port or extension set), could cause bleeding or infection. Maintaining a 90 degree angle while rotating the catheter will insure proper removal without complications. * Be certain that you DO NOT ROCK the catheter while removing. Rocking or bending the catheter with a syringe may cause the catheter to separate from the hub! If hub-catheter separation occurs use an appropriate hemostat to grasp and gently remove the catheter in the same manner as suggested above (rotating while gently pulling). The EZ-IO® catheter should be removed within 24 hours! Removal of the EZ-IO® catheter is simple. You may either grasp the hub directly or attach a sterile syringe. (The syringe will serve as a larger handle for the catheter hub and is preferred) Support the patient’s extremity while rotating the catheter clockwise and gently pulling. (Recall that the exterior portion of the catheter is smooth or not threaded). Rotating the hub during removal reduces catheter to bone friction and will allow for an easier removal process. Be careful with the sharp catheter once removed from the patient! Once the catheter has been removed immediately place it in an FDA approved bio hazard sharps container. We recommend that you place a portable sharps container near the patient for this procedure (example - P2 Sharps Shuttle by Tyco/Kendall) Removal of the extension or fluid administration set, without proper protection of the EZ-IO® hub (in the form of a sterile cap, port or extension set), could cause bleeding or infection. Maintaining a 90 degree angle while rotating the catheter will insure proper removal without complications. * Be certain that you DO NOT ROCK the catheter while removing. Rocking or bending the catheter with a syringe may cause the catheter to separate from the hub! If hub-catheter separation occurs use an appropriate hemostat to grasp and gently remove the catheter in the same manner as suggested above (rotating while gently pulling).

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