Intraosseous Vascular Access

1. Intraosseous Vascular Access

2. The System

3. EZ-IO Training Materials • PowerPoint™ Presentations • With comprehensive notes located behind each slide • EZ-IO StarCast Presentations • Quick Reference Card • Insertion & Removal Poster • Training Mannequins • Training Driver & Needle Sets • Complete Web Site • Clinical Support Hotline

4. The EZ-IO Lithium Driver Sealed cap Lithium Batteries Designed for 1000 human insertions

5. Needle set packaging

6. The EZ-IO Needle Sets Specialized tip EZ-IO Needle Set (safety cap removed) EZ-IO Needle Set (“X-Ray View” with safety cap) Stylet Hub Catheter & Stylet Stylet Catheter & Catheter Hub Metal Disc Needle Set Safety Cap

7. EZ-IO PD & EZ-IO AD needle sets 15 mm in length 5 mm mark 25 mm in length Length and color are the only differences between PD & AD needle sets

8. Open Cartridge Note: Needle Set’s position Note: torn (and lifted) safety seal Sealed Sterile Cartridge Note: “lot code and expiration” moved to cartridge barrel Open Cartridge Note: torn (and lifted) safety seal Open Cartridge Note: exposed “single use only” sticker Stylet in “Shuttle” Note: REMOVED safety seal Stylet in “Shuttle” Note: REMOVED safety seal

9. Put it where it belongs! Stylets belong in approved sharps containers

10. Consider these points BEFORE EVERY EZ-IO insertion: • Did you “hear” a pop when the cartridge was opened? • Did the Driver easily attach to the Needle Set (With the Needle Set remaining in the cartridge)? • Did you REMOVE the Needle Set Safety Cap from the Needle Set? • Did you CONFIRM the 5 mm mark? Needle Set Note that a “lone Stylet” sits deeper than a complete Needle Set Important EZ-IO usage considerations

11. Precise cylindrical hole created by EZ-IO insertion

12. The EZ-IO Infusion Solution EZ-IO Storage Cases & Cradle Training Driver EZ-Connect Wristband Training Needle Sets EZ-IO Driver EZ-IO AD & PD Needle Sets

13. General IO Anatomy

14. Anatomyof intraosseous access Thousands of small veins lead from the medullary space to the central circulation

16. Adult IO Anatomy

17. Proximal Tibial Anatomy

18. Distal Tibial Anatomy

19. The ankle joint is comprised of the Tibia, Talus and Fibula

20. Proximal Humeral Anatomy

21. Insertion site Insertion site

22. The Proximal Humerus insertion site is found “slightly anterior to the arms lateral midline” Right arm Adult male Note that arm is adducted with the elbow posteriorly placed!

23. Pediatric IO Anatomy

24. If the patient “fits” on the Broselow™ Tape THINK PINK* and use the EZ-IO PD = *Obese pediatric patients may require the EZ-IO AD needle Set

25. Pediatric Anatomical Overview

26. The pediatric growth plate Clearly visible tibial growth plate Growth Plate Insertion site Tibia Right Leg Left Leg

27. Identifying the EZ-IO PD insertion site If the Tibial Tuberosity CANNOT be palpated the insertion site is two finger widths below the Patella (and then) medial along the flat aspect of the Tibia The Tibial Tuberosity can be difficult or impossible to palpate on younger patients

28. Identifying the EZ-IO PD insertion site If the Tibial Tuberosity CAN be palpated the insertion site is one finger width below the Tuberosity (and then) medial along the flat aspect of the Tibia As patients mature the Tibial Tuberosity becomes easier to identify

29. Indications

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

31. Indications for Intraosseous Access • Patients with poor peripheral access • Dialysis Patients • Sickle Cell Patients • Obese Patients • Mass casualty incidents • (shootings, motor vehicle collisions) • Congestive Heart Failure • Oncology Patients • IV Drug Abuse • Dehydration (especially pediatrics) • Diabetic Patient (DKA or hypoglycemia) Consistent with the AHA & ERC Guidelines Intraosseous Access = Immediate Vascular Access

32. AHA, ERC, ILCOR, NAEMSPGuidelines • IOshould 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 ILCOR is comprised of seven formal members – American Hear Association, European Resuscitation Council, Heart and Stroke Foundation of Canada, Australian and New Zealand Committees on Resuscitation, Resuscitation Councils of Southern Africa, and the InterAmerican Heart Foundation and Resuscitation Council of Asia

33. What About Infections With IO • 20 + year history in pediatrics with Cook/Jamshidi needles sets • Overall infection rate is 0.6% • Cases of osteomylitis occurred when catheter was left in place for > 72 hours • Newer IO devices cause less bone trauma • EZ-IO database • Contains 2000+ insertions with no local infections or osteomylitis • Estimate of 80,000+ insertions with no local infections or osteomylitis

34. Intraosseous access: is it painful? • IO insertion pain is equivalent to a peripheral IV • IO infusion pain can be severe but is significantly moderated by the administration of 20 – 40 mg Lidocaine for patients > 39kgs and 0.5mg/kg for patients 39kgs or less via the IO route (*2% preservative free Lidocaine is recommended)

36. 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 for patients > 39kgs and 5cc flush for patients 39kgs or less dramatically increases IO flow rates NO FLUSH = NO FLOW

37. Infusion of Medication • Which Drugs can be given? • Any medications that can be safely injected into a central venous catheter can be safely injected IO • What Dose? • IO and IV doses are identical • Lab Testing: • 10 - 15 cc of blood can be aspirated from an IO device and placed into a syringe for standard laboratory testing

38. The Reality of Intraosseous Flow Immediate flow from the tibia and proximal humerus to the central circulation

39. Contraindications • Local Infection (at the insertion site) • Fractures (to the bone selected for insertion) • Prosthesis • Recent (24 hours) IO in same extremity • Absence of anatomical landmarks or excessive tissue

40. EZ-IO Access The art of insertion

41. Observe Body Substance Isolation Precautions

42. Adult

43. Confirm and clean insertion site

44. Confirm and clean insertion site

45. Identify the Proximal Humerus insertion site Elbow should remain adducted and posteriorly located Place the hand over the umbilicus for humeral positioning and safety orient the arm to this position

46. Preferred insertion site identification method Place patient in supine position with the arm correctly oriented

47. Coracoid Process Acromion This alternate method of identification can be used in association with the preferred method to ensure proper placement Alternate site identification method

48. Confirm and clean insertion site

49. Pediatric

50. Confirm and clean insertion site