EZ-IO

1. EZ-IO By Elspeth Richardson

2. History • Used in WWII in resusciation of haemorrhagic shock but then fell out of practice afterwards • Rediscovered by paediatrician James Orlowski visiting India during cholera epidemic, and has been standard of practice in paediatric life support guidelines since 1980’s • Used less widely in adults, but now recommended in some resus guidelines as 1st alternative in difficult IV access in cardiac arrest setting1 • Central line out of favour in resus setting; ET route gives lower and more variable concentrations

3. Science? • Access through BV’s in BM held open by rigid non-collapsible bony wall (don’t collapse in shock) which flow into central venous system 3,4 • Quickly absorbed into systemic circulation - nearly identical to IV (ie. within 1 second) 5, 6 • Can deliver any blood products / fluids / drugs - including high volumes that can’t be given via ET • Lasts 24-48hrs

4. Why? • “The Golden Hour” - potential for saving critically ill patients at it’s optimum • Significant numbers don’t receive necessary pre-hospital therapy due to difficult IV access1 • Access can be achieved in <1min without serious complications assoc with central lines

5. When? • APLS: Recommended technique for access in paediatric cardiac arrest; otherwise recommended if >3 attempts or >1.5mins to gain access in critically ill child • Quick IV access in shock, cardiac arrest, trauma, combative, disaster/military medicine, mass casualty scenarios • Obviously, difficult IV access • Paediatric patients - IV access unobtainable in 6% or more2 • Can be considered a ‘bridge’ to a central line

6. How? • Little training required, good success rate (95% or more) in <60secs in most cases1 (central lines take 11-25mins) • Only 15% will be conscious, but those will need LA (average pain score on insertion without LA is 2.5/10, or equivalent to insertion of 18-16 guage peripheral line ); some report significant pain on infusion • Suggest initial push of 20-40mg 2% lidocaine (0.5mg/kg paediatric) after insertion to block pressure centres in IO space (not >3mg/kg/24hrs) --> then, after 15-30secs, give 10ml 0.9% saline flush • Need pressure bag - flow rate alters by 69-92ml/min

7. Sites? • Proximal tibia - anteromedial surface, 2-3cm below tibial tuberosity, at 90deg to skin but pointing caudally to avoid growth plate • Distal tibia • Femoral - anterolateral surface, 3cm above lateral condyle

8. Sites? • Anterolateral proximal humerus • Sternum (not good for CPR), superior iliac crest • Confirm placement by aspirating 5mls blood or flushing. Placement successful if sudden give / needle stands alone / fluid flows easily • No significant difference between infusion rates (humeral vs tibial)1

9. Device? • Manual device / impact driven device (‘bone injection gun’ - spring-loaded needle) / powered drill (EZ-IO - in anyone >3kg)) • Pink - 3-39kg • Blue - >40kg • Yellow - prox humerus >40kg, or much subcutaneous tissue

10. Cost? • IV line: $3 - 5, although may be multiple attempts • IO line: $65 - 165 • CV line: $200 for kit, $200 for X-ray; much more costly if gets infected • Less equipment, less personel, less time, quicker treatment, less ICU admissions, less complications • According to website, EZ-IO has small environmental footprint!

11. Complications • Complications are rare • Obese - needle not long enough to reach BM space • 0.6% rate of osteomyelitis - usually only if prolonged or patient bacteraemic at time of insertion1 • Others: subcutaneous/subperiosteal infiltration during use, dislodgement, slow flow rate, fracture, compartment syndrome, skin necrosis, clogging of needle (frequent flushes), through-and-through penetration, pneumothorax / vascular injury / mediastinitis if sternal, haematoma, growth plate injuries • Contraindicated in: previous sternotomy, fractures above IO site, previous attempt in same leg/site, previous orthopaedic surgery in area of insertion, infection at insertion site, local vascular compromise, osteogenesis imperfecta, osteoporosis