Intraosseous Needle Insertion

1. Intraosseous Needle Insertion Kalpesh Patel, MD Dept. of Pediatric Emergency Medicine November 22, 2006

2. Objectives • Understand the history of intraosseous needles (IO) • Understand the indications, risks, and benefits of IO needle insertion • Learn to perform: • IO needle insertion at various locations using the manual insertion method • IO needle insertion using new techniques

3. History • Earliest reference to IO use was in 1922 • First theraputic use in humans was reported in 1934 • Popularized in the 1940’s for rapid access • Used widely until 1950’s when the plastic catheter was devised • Reemerged in mid 80’s for resuscitation where IV access was difficult • Since then, pediatric use has become more accepted • Now used as the standard of care for emergency access in both pediatrics and adults

4. Physiology • The marrow cavity is in continuity with the venous circulation and functions as a non-collapsable venous plexus • Sinusoids serve as transport to the central venous channel exiting as nutrient and emissary veins

5. Physiology • The onset of action and drug levels during CPR using the IO route are similar to those given IV • Used to infuse fluids, blood products, and drugs • Can take mixed venous blood samples for labs such as crossmatch, bedside tests, etc.

6. Indications • When vascular access is needed in life-threatening situations • When attempts at standard venous access fail (three attempts or 90 seconds) or in cases where it is likely to fail and speed is of the essence.

7. Contraindications • Femoral fracture on the ipsilateral side • Do not use fractured bones • Do not use bones with osteomyelitis • Osteogenesis Imperfecta • Osteopetrosis

8. Types of IO Needles Jamshidi IO Needle Cook IO Needle Sur-Fast IO Screw Tip Needle Illinois Sternal Iliac Needle

9. Equipment Required • Antiseptic prep solution • Local Anesthetic (optional in the moribund patient) • IO Needles • 18-20 gauge spinal needle can be used as an alternative • In a pinch, any needle can be used, but may get clogged with cortical bone without stylet or trochar • Syringe • Flush solution • Gauze pads and tape

10. Locations of Insertion • 3 most common locations: • Proximal Tibia • Medial side, 1-2 cm below and avoiding the tibial tuberosity

11. Locations of Insertion • Distal Femur • Femur is triangular shaped. Insert needle 1-2 cm proximal to the superior border of patella and medial or lateral to anterior ridge • Distal Tibia • 1-2 cm proximal to the medial malleolus in the center of the bone

12. Locations of Insertion • In older children and adults: • Iliac crests, preferably Anterior Superior Iliac Spine • Sternum

13. Technique for Manual Insertion • Prep the site • Inject 1-3 ml of lidocaine into the skin and down to the periosteum (optional when time does not permit this) • Grasp needle in dominant hand and place it on the site with the needle pointing away from the joint • Pinch needle with thumb and forefinger and allow the hub to rest in the palm of your hand • DO NOT PLACE YOUR OTHER HAND BENEATH THE SITE

14. Technique for Manual Insertion • Use firm downward pressure and rotate the needle back and forth • Feel for a sudden decrease in resistance or a popping sound and advance the needle a few millimeters • Remove the trochar or stylet and aspirate marrow

15. Technique for Manual Insertion • Infuse fluid to determine ease of flow and no extravasation in to soft tissues around the insertion site • Secure the needle with goal post taping to allow visualization of the site • If the needle fails, then insert into a new bone because fluid will leak from the failed site

16. IO Insertion http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=1528&id=1347

17. Complications • Through and through penetration • Extravasation of fluids or medications into subcutaneous tissue • Compartment syndrome • Subcutaneous abscess/skin necrosis • Osteomyelitis • When an aseptic technique is used, the incidence of osteomyelitis is less than 1% • Bacteremia • Epiphyseal injury and fracture (especially in neonates) • Fat Embolus • Bent needle • Complications are reported to occur in <1% of cases

18. New Methods • F.A.S.T -1 system • Bone Injection Gun (BIG) • EZ-IO Drill

19. F.A.S.T. -1 Sternal Intraosseous Device • First Access for Shock and Trauma • Created for insertion into manubrium of adult sternum • May be used in older children • http://www.pyng.com/movies/iousemovie.html

20. Bone Injection Gun • Spring loaded catheter injected into place at a preset depth • Comes in Adult and Pediatric sizes • Establishes access within 1 minute

21. BIG, The Movie http://www.ps-med.com/big/description_big01.html

22. EZ-IO • A battery powered electric drill which places the needle quickly into place

23. EZ-IO Insertion http://www.vidacare.com/Products/index_4_29.html

24. Aftercare • IO’s are emergency lines and every effort should be made to place an intravenous line after initial resuscitation • IO’s should ideally be removed within 6-12 hours • All IO’s will eventually start to leak • IO’s can stay in for up to 48-72 hours, but after 24 hours the risk of osteomyelitis increases dramatically

25. Summary • IO’s are essentially equivalent to IV access • Should be used for emergency access • Many types of needles exist, but Jamshidi style is preferred by most users • Preferred insertion sites include proximal or distal tibia, or distal femur, but in older children, iliac crests and sternum can be considered • New devices are emerging, but are not standard of care in pediatrics yet

26. Questions?