Intraosseous access: Difference between revisions
 
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==Indications==
==Indications==
[[File:ez-IO.jpg|thumbnail|3 EZ-IO sizes]]
[[File:ez-IO.jpg|thumbnail|3 EZ-IO sizes]]
*immediate access required for administration of drugs/fluids  
 
*cardiac arrest, resuscitaion when no other IV in place  
*Immediate vascular access required for administration of drugs/fluids  
*Do not use IO for more than 24 h (ideally place the IO for immediate resus needs, then establish peripheral or central lines as needed)
*Cardiac arrest, resuscitation when no other IV in place  
 
[[File:IO sizes.JPG|thumbnail|15 Gauge IO sizes]]


==Contraindications==
==Contraindications==
*Osteoporosis  
*Osteoporosis  
*[[Osteomyelitis]]
*[[Osteomyelitis]]
*steogenesis imperfecta  
*[[Osteogenesis imperfecta]]
*[[Fractures_(Main)|Fractured bone]]
*[[Fractures_(Main)|Fractured bone]]
**Extravasation of fluid can lead to [[compartment syndrome]]
*Recent IO infusion in same bone  
*Recent IO infusion in same bone  
*[[Cellulitis]], Infection, or Burn, at insertion site
*[[Cellulitis]], infection, or [[burn]], at insertion site


==Equipment==
==Equipment==
*Multiple different types of IO needles and products available
*EZ-IO drill (other products/brands available)
 
*Appropriate IO needle with extension set  
#EZ-IO drill
*Chloraprep or alcohol swabs
#Appropriate IO needle with extension set  
*Saline Flush  
#Chloraprep or alcohol to clean skin
*[[Lidocaine]] (2% lidocaine without epi)
#Saline Flush  
#Lidocaine (2% lidocaine without epi)


==Site Selection==
==Site Selection==
#Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia  
*Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia  
#Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein  
*Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein  
#Proximal humerus (adults only, use yellow needle)
*Proximal humerus (adults only, use yellow needle) <ref> http://www.acep.org/WorkArea/DownloadAsset.aspx?id=48943 </ref>
#Distal Femur (generally only in infants and children)
**keep arm adducted and internally rotated (hand on bellybutton)
#Pelvic ASIS
**slide fingers up humerus until you feel a notch (surgical neck)
**insert IO 1cm above surgical neck into the greater tubercle
**immobilize arm or IO will displace (no abduction at shoulder)
*Distal Femur (generally only in infants and children)
*Pelvic ASIS
*Sternum (Has highest flow rate of any location)


==EZ-IO Needle selection (based on weight of patient)==
==EZ-IO Needle selection (based on weight of patient)==
#Pink 15mm (3-39kg)  
*Pink 15mm (3-39kg)  
#Blue 25mm (40kg and above)  
*Blue 25mm (40kg and above)  
#Yellow 45mm&nbsp; (excessive tissue)
*Yellow 45mm&nbsp; (excessive tissue or humerus)


==Procedure==
==Procedure==
#Identify landmarks  
*Identify landmarks  
#Clean skin  
*Clean skin  
#Place appropriate needle on drill and remove safety cap  
*Place appropriate needle on drill and remove safety cap  
#ADVANCE needle through skin to bone
*ADVANCE needle through skin to bone
#DRILL needle perpendicular into bone at site with gentle, constant pressure  
*5 mm of the catheter (at least one black line) must be visible outside the skin
#When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)  
*DRILL needle perpendicular into bone at site with gentle, constant pressure  
#Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space  
*When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)  
#Remove stylet  
*Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space  
#Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)  
*Remove stylet (''caution: stylet is extremely sharp'' - place in sharps container)
#Aspirate blood/marrow to confirm placement  
*Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)  
#If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)  
*Aspirate blood/marrow to confirm placement  
#Flush saline through extension set to ensure good flow  
*If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)  
#Apply dressing  
*Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
#'''REMOVAL:''' detach extension tubing. place a 12mL empty syringe on IO luer lock. twist clockwise while gently and slowly applying in-line traction until removed. apply dressing
*Apply dressing
 
===Removal===
*Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
**Can attach syringe via luer lock to act as handle
*Apply dressing.
 
(IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved<ref>Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.</ref>)


==Complications==
==Complications==
*[[Compartment syndrome]]
*Incomplete penetration of cortex  
*Incomplete penetration of cortex  
*Penetration of posterior cortex  
*Penetration of posterior cortex  
Pain
*Infection ([[cellulitis]], [[osteomyelitis]])
*Infection  
*[[Fracture]]
*Compartment syndrome
*Growth plate damage  
*Growth plate damage  
*Fat embolism
*[[Fat embolism]]


==Labs drawn via IO==
==Labs drawn via IO==
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*CANNOT use IO blood for CBC
*CANNOT use IO blood for CBC
**WBCs are higher and platelet counts are lower<ref name="miller"></ref>
**WBCs are higher and platelet counts are lower<ref name="miller"></ref>
*Only need to discard 2mL of blood prior to sending to lab


==IO Medications==
==IO Medications==
*Any medication that can be given in peripheral IV can be given through IO  
*Any medication that can be given in peripheral IV can be given through IO  
**Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line<ref>Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.</ref>
**[[Epinephrine]] infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line<ref>Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.</ref>
**RSI medications can be given through IO with the same efficacy<ref>Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]</ref>
**[[RSI]] medications can be given through IO with the same efficacy<ref>Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]</ref>
*Same doses as IV meds  
*Same doses as IV meds  
*Follow with flush
*Follow with flush
*Drips or IV fluids should be given with pressure bag or infusion pump
*Drips or IV fluids should be given with pressure bag or infusion pump


==Source==
==IO and CT contrast==
*Overall safe and effective
*Case reports with successful venous opacification in a trauma patient <ref> Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386 </ref>
*Successful CTA [[PE]] protocol reported <ref> Ahrens, et al. Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report. Journal of Emergency Medicine. 2013; 45 (2): 182-184 </ref>
*Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure) <ref> Miller, et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4) 240-241. </ref>
 
==See Also==
{{Vascular access types}}
 
==External Links==
*[https://www.teleflex.com/usa/en/product-areas/emergency-medicine/intraosseous-access/arrow-ez-io-system/index.html Teleflex EZ-IO]
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-peripheral-vascular-procedures/how-to-do-intraosseous-cannulation,-manually-and-with-a-power-drill?query=intraosseous Merk Manual - How To Do Intraosseous Cannulation]
 
===Videos===
*EMRAP (3:12) https://www.youtube.com/watch?v=KHXSfh2ZRDM
 
==References==
<references/>
<references/>
[[Category:Procedures]][[Category:Airway/Resus]]
 
[[Category:Procedures]]
[[Category:Critical Care]]

Latest revision as of 00:46, 16 July 2021

Indications

3 EZ-IO sizes
  • Immediate vascular access required for administration of drugs/fluids
  • Cardiac arrest, resuscitation when no other IV in place
15 Gauge IO sizes

Contraindications

Equipment

  • EZ-IO drill (other products/brands available)
  • Appropriate IO needle with extension set
  • Chloraprep or alcohol swabs
  • Saline Flush
  • Lidocaine (2% lidocaine without epi)

Site Selection

  • Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
  • Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
  • Proximal humerus (adults only, use yellow needle) [1]
    • keep arm adducted and internally rotated (hand on bellybutton)
    • slide fingers up humerus until you feel a notch (surgical neck)
    • insert IO 1cm above surgical neck into the greater tubercle
    • immobilize arm or IO will displace (no abduction at shoulder)
  • Distal Femur (generally only in infants and children)
  • Pelvic ASIS
  • Sternum (Has highest flow rate of any location)

EZ-IO Needle selection (based on weight of patient)

  • Pink 15mm (3-39kg)
  • Blue 25mm (40kg and above)
  • Yellow 45mm  (excessive tissue or humerus)

Procedure

  • Identify landmarks
  • Clean skin
  • Place appropriate needle on drill and remove safety cap
  • ADVANCE needle through skin to bone
  • 5 mm of the catheter (at least one black line) must be visible outside the skin
  • DRILL needle perpendicular into bone at site with gentle, constant pressure
  • When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)
  • Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
  • Remove stylet (caution: stylet is extremely sharp - place in sharps container)
  • Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
  • Aspirate blood/marrow to confirm placement
  • If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)
  • Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
  • Apply dressing

Removal

  • Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
    • Can attach syringe via luer lock to act as handle
  • Apply dressing.

(IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved[2])

Complications

Labs drawn via IO

  • Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
    • There is not good correlation with Sodium, Potassium, CO2, and calcium levels.[3]
    • Potassium is often elevated due to hemolysis
  • CANNOT use IO blood for CBC
    • WBCs are higher and platelet counts are lower[3]
  • Only need to discard 2mL of blood prior to sending to lab

IO Medications

  • Any medication that can be given in peripheral IV can be given through IO
    • Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line[4]
    • RSI medications can be given through IO with the same efficacy[5]
  • Same doses as IV meds
  • Follow with flush
  • Drips or IV fluids should be given with pressure bag or infusion pump

IO and CT contrast

  • Overall safe and effective
  • Case reports with successful venous opacification in a trauma patient [6]
  • Successful CTA PE protocol reported [7]
  • Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure) [8]

See Also

Vascular access types

External Links

Videos

References

  1. ↑ http://www.acep.org/WorkArea/DownloadAsset.aspx?id=48943
  2. ↑ Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.
  3. ↑ 3.0 3.1 Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.
  4. ↑ Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.
  5. ↑ Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]
  6. ↑ Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386
  7. ↑ Ahrens, et al. Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report. Journal of Emergency Medicine. 2013; 45 (2): 182-184
  8. ↑ Miller, et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4) 240-241.
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