The 5 Rights of Intraosseous Vascular Access

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The 5 Rights of the EZ-IO

1. The Right Site

2. The Right Needle

3. The Right Pain Management

4. The Right Flush

5. The Right Amount of PressureT-430 Rev, G

Who Needs an IO?

• For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.

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“I Can ALWAYS Get a Line…”

• Excessive Tissue

• Burns

• Dehydration

• Renal patients

• Sepsis

• Diabetics

• Hypertensive Crises

• “C” before “A”?

• Major Trauma

• IVDA

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Is it adequate vascular access?

Contraindications

• Fracture to the targeted bone

• Previous orthopedic procedure to targeted limb– Prosthetic limb or joint

• IO within the past 24 - 48 hours in the targeted bone

• Infection at the insertion site

• Inability to locate landmarks or excessive tissue

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Thousands of small veins lead from the medullary space to the central circulation.

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Anatomy of Intraosseous Access

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Real-time Flow Rate Studies

The Right Site

Site selection is dependent upon:

• Absence of contraindications

• Accessibility of the site

• Ability to monitor and secure the site

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The Right Needle

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

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Length and color are the only differences between Needle Sets

25 mm/15g 45 mm/15g

5 mm mark or

“black line”

15 mm/15g

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15 gauge

Three Needle Sets

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Egg Insertion Video

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

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Laboratory Analysis• Attach syringe directly to the secured

and stabilized hub

• Draw 2ml for waste or blood cultures

• Aspirate IO blood for standardized labs

• May use heparinized syringe

• Label tubes as IO blood

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IO Lab Analysis StudyCompared lab results between IO and IV in human volunteers

• The following lab values produced a statistically significant correlation between IO and venous blood: - Chloride - Calcium

- BUN - Creatinine - Hematocrit - Hemoglobin - Glucose

• WBC was higher

• Blood gases – IO values were between arterial and venous

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Confirm and Clean Insertion Site

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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

Cau

tion

!

Cau

tion

!

Recoi

l!

Recoi

l!

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The Tibial Tuberosity can be difficult or impossible to palpate on younger patients

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

Identifying the pediatric EZ-IO insertion site

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As patients mature the Tibial Tuberosity becomes easier to identify

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

Identifying the pediatric EZ-IO insertion site

Prepare EquipmentInspect 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)

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Remove Needle Set Safety Cap

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Stabilize Extremity

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

Insert Needle Set at a 90o angle to the bone – insert through the skin until you touch bone

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Note that the 5 mm

mark is NOT visible

above the skin

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Appropriate Needle Set

Selection Matters!

Note that a black line is NOT

visible above the skin

Needle Sizes

 Consider tissue depth PRIOR to bone insertion

Black line

Apply the minimal amount of pressure required to keep the driver advancing straight into the bone.

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Do not Apply Excessive Force

Remove Driver from Needle Set

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Stabilize the Needle Set while disconnecting Driver.

• 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

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Removal of the Stylet

Portable sharps protector

Put Stylets Where They Belong . . .

in approved biohazard containers.T-430 Rev, G

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

Monitor for signs of extravasation.

Confirm Catheter Placement

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Intraosseous Usage and Pain

Insertion pain is specific,

and of short duration

Infusion pain is general,

diffuse and protracted T-430 Rev, G

Sometimes it Hurts…

• Foley Catheter

• Nasogastric Tube

• Multiple IV Sticks

• Central Lines

• Spinal Taps

• IM Injections

• Adhesive Removal

• Dressing Changes

• Wound Debridement

• Clysis

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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 rangeT-430 Rev, G

The Right Flush

• 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

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No Flush = No Flow

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

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The Right Amount of Pressure

• 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

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

Infuse Fluids with Pressure

IO Care and Use

• Flush with 3-5ml of saline before and after medication administration

• The IO space is hypercoagulable and may need to have a continuous flow of fluids and/or may need be flushed several times throughout treatment to avoid clotting

• Continually reassess and manage infusion related pain

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Troubleshooting

If fluids will not infuse:

• Disconnect IV tubing from EZ-Connect extension set and flush EZ-Connect with 10ml of saline

• To obtain maximum flow rates, infuse with pressure (pressure bag, rapid infuser or pump)

• Assure the clamp on the EZ-Connect is open

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If fluids will not infuse:

• If EZ-Connect appears to be occluded, replace extension set

• If infusing with a rapid infuser or pump, troubleshoot the infusion equipment

• If unable to restore flow through the IO, or if signs of extravasation or edema develop, remove the IO and replace at an alternative site if IO vascular access is still necessary

Troubleshooting

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Troubleshooting

If fluids will not infuse:

• Consider heparin lock between uses

• Consider heparin or urokinase to open blocked IO– Follow your institutional policy for clotted vascular access

devices

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EZ-IO Removal

Back the EZ-IO catheter out of patient while stabilizing the extremity.

Maintain axial alignment – DO

NOT rock the syringe

Rotate syringe clockwise while

pulling straight back

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Aftercare

• Following EZ-IO removal, apply gentle pressure and dress site appropriately

• Inform the patient that soreness is normal for up to forty-eight hours following removal

• There are no weight bearing or ambulation restrictions following removal of the IO

• The patient should be able to assume normal activities as soon as their primary medical condition allows

• Notify physician if signs and symptoms of infection develop at or around the insertion site

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The 5 Rights of the EZ-IO

1. The Right Site

2. The Right Needle

3. The Right Pain Management

4. The Right Flush

5. The Right Amount of PressureT-430 Rev, G

DO NOT SUBMERGE DRIVER AT ANY TIME

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

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Clinical Support

• Wrist band

• 24 hour Emergency Line • 1-800-680-4911

• www.vidacare.com

• Web Feedback form

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Questions?

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Please review “Directions For Use” before using the EZ-IO.