The 5 Rights of Intraosseous Vascular Access

1. The 5 Rights of Intraosseous Vascular Access Linda Arapian RN MSN MCFRS T-430 Rev, F

2. The 5 Rights of the EZ-IO • The Right Site • The Right Needle • The Right Pain Management • The Right Flush • The Right Amount of Pressure T-430 Rev, G

3. Who Needs an IO? • For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.

4. Maryland Medical Protocols July 2011 • INDICATIONS FOR IO • Cardiac arrest, OR • Profound hypovolemia, OR • No available vascular access, or following two unsuccessful peripheral IV attempts for patients with..life-threatening illness or injury requiring immediate pharmacological or volume intervention, OR • In pediatric patients in cardiac arrest, go directly to IO if no peripheral sites are obvious and without having to attempt peripheral access

5. Contraindications • Fracture to the targeted bone • Previous orthopedic procedure to targeted limb • Prosthetic limb or joint • IO within the past 48 hours in the targeted bone • Infection at the insertion site • Inability to locate landmarks or excessive tissue T 430 Rev G

6. Maryland Medical Protocols July 2011Contraindications ADDITIONAL Contraindications for IO placement: • Conscious patient with stable vital signs • Peripheral access readily available

7. Anatomyof Intraosseous Access Thousands of small veins lead from the medullary space to the central circulation. T-430 Rev, G

8. The IO space is filled with a thick fibrin mesh The medullary space must be pressure flushed to obtain maximum flow rates 10ml of normal saline is required for initial bolus Flush must overcome initial resistance felt with bolus administration More than one flush may be required to achieve maximum flow rate The Right Flush T-430 Rev, F

9. Site selection is dependent upon: Absence of contraindications Accessibility of the site Ability to monitor and secure the site NOTE: Sternum is NOT a site The Right Site T-430 Rev, G

10. Maryland Medical Protocols July 2011Acceptable Sites Manual placement • Under 6yo – proximal tibia site • Over 6 yo – distal tibia site Mechanical Placement • 3-39 Kg - proximal tibia • > 40 Kg - adult needle in proximal tibia • > 40 Kg - adult needle in distal tibia (needle length) • > 40 Kg - use proximal humerus if lower extremity not available - proximal humerus not approved < 40 Kg

11. Confirm and Clean Insertion Site T-430 Rev, G

12. Three Needle Sets 5 mm mark or “black line” 15 gauge 15 mm/15g 25 mm/15g 45 mm/15g Length and color are the only differences between Needle Sets T-430 Rev, G

13. Selection based on: Needle Length (15 mm, 25 mm, and 45 mm) Soft tissue depth estimated by using your finger Visualization of a black line after penetration of the skin The 45 mm needle should be considered for all proximal humerus insertions – patients >40 kg Special situations Excessive soft tissue Excessive muscle tissue Edema The Right Needle T-430 Rev, G

14. Note that a black line is NOT visible above the skin Appropriate Needle Set Selection Matters! Note that the 5 mm mark is NOT visible above the skin Black line Needle Sizes  Consider tissue depth PRIOR to bone insertion T-430 Rev, G

15. Prepare Equipment Inspect needle packaging for damage and sterility Open EZ-Connect and prime w/saline (or consider 2% lidocaine for patients responsive to pain) Leave syringe attached to EZ-Connect Open package and attach Driver to Needle Set (leave cap on needle until ready to insert) T-430 Rev, G

16. Remove Needle Set Safety Cap T-430 Rev, G

17. Stabilize Extremity Guard against unexpected patient movement. T-430 Rev, G

18. Insert Needle Set at a 90o angle to the bone – insert through the skin until you touch bone T-430 Rev, G

19. Do not Apply Excessive Force Apply the minimal amount of pressure required to keep the driver advancing straight into thebone. T-430 Rev, G

20. Pediatric EZ-IO Insertion Pediatric insertion requires a gentle grip and a soft touch One size does not fit all - Consider tissue depth in needle selection Be cautious of driver recoil - Release the trigger when you feel the lack of resistance The EZ-Stabilizer is highly recommended on newborns and infants Recoil! Caution! T-430 Rev, G

21. Remove Driver from Needle Set Stabilize the Needle Set while disconnecting Driver. T-430 Rev, G

22. Stabilize Needle Set and rotate the stylet counter-clockwise Remove stylet and dispose of in approved bio-hazard sharps container Apply EZ-Stabilizer before attaching the primed EZ-Connect Removal of the Stylet T-430 Rev, G

23. Put Stylets Where They Belong . . . in approved biohazard containers. Portable sharps protector T-430 Rev, G

24. Note one or more of the following: Firmly seated catheter Flash of blood in the catheter hub or blood on aspiration * Pressurized fluids flow without difficulty Pharmacologic effects * may or may not be able to aspirate blood Confirm Catheter Placement Monitor for signs of extravasation. T-430 Rev, G

25. Syringe FLUSH Catheter Prime and use extension set Flush IO catheter with 10ml of saline Reminder: For patient’s responsive to pain consider 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) via the IO PRIOR to syringe flush Some patients may require multiple syringe flushes No Flush = No Flow T-430 Rev, G

26. What Can be Infused? • Any medication that can be safely given through a peripheral vein can be given safely through an IO • IO and IV doses are the same T-430, Rev G

27. Intraosseous Usage and Pain Insertion pain is specific, and of short duration Infusion pain is general, diffuse and protracted T-430 Rev, G

28. Pain Management • Consider IO 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) for patients responsive to pain prior to flush. Follow institutional protocols/policies. • Medications intended to remain in the medullary space, such as a local anesthetic, must be administered very slowly until the desired anesthetic effect is achieved. *Physician must determine appropriate dosage range T-430 Rev, G

29. Maryland Medical Protocols July 2011Pain Management Pain due to IO infusion: Adults administer 20-40 mg of 2% cardiac lidocaine (1-2 mL 2% Lidocaine) IO Ped > 40Kg administer 20-40mg of 2% cardiac lidocaine (1-2 mL 2% Lidocaine) IO Peds < 40Kg Medical consultation is required

30. The pressure in the medullary space is approximately 1/3 of the patients arterial pressure Pressurizing fluids for infusion is required to obtain maximum flow rates For aggressive fluid resuscitation a rapid infuser may increase flow rates Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered. T-430 Rev, F

31. Infuse Fluids with Pressure Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered. T-430 Rev, G

32. Clinical Support • Wrist band • 24 hour Emergency Line • 1-800-680-4911 • www.vidacare.com • Web Feedback form T-430 Rev, G

33. Maintain axial alignment – DO NOT rock the syringe EZ-IO Removal Rotate syringe clockwise while pulling straight back Back the EZ-IO catheter out of patient while stabilizing the extremity. T-430 Rev, G

34. Cleaning & Disinfecting Wipe clean with moistened cloth Spray with anti-microbial solution Momentarily depress trigger several times during cleaning Clean around drive shaft with cotton applicator – check to ensure nothing has attached to the magnetic tip Wipe dry Inspect driver and return to case or replace trigger guard DO NOT SUBMERGE DRIVER AT ANY TIME T-430 Rev, G

35. Please review “Directions For Use” before using the EZ-IO. VIDACARE Regional Clinical Contact: Karen Hust RN MSN CEN Clinical Manager - Mid-Atlantic Territory (NJ, PA, DE, Washington DC, VA, WV, NC) 912-308-1839 Immediate Vascular Access…              When You Need It Most www.vidacare.com T-430 Rev, F

36. The 5 Rights of the EZ-IO Review • The Right Site • The Right Needle • The Right Pain Management • The Right Flush • The Right Amount of Pressure T-430 Rev, G

37. Questions? Please review “Directions For Use” before using the EZ-IO. T-430 Rev, G

38. The pressure in the medullary space is approximately 1/3 of the patients arterial pressure Pressurizing fluids for infusion is required to obtain maximum flow rates For aggressive fluid resuscitation a rapid infuser may increase flow rates The Right Amount of Pressure T-430 Rev, G

39. “I Can ALWAYS Get a Line…” • Excessive Tissue • Burns • Dehydration • Renal patients • Sepsis • Diabetics • Hypertensive Crises • “C” before “A”? • Major Trauma • IVDA Is it adequate vascular access? T-430 Rev, G