1 Explore. Discover. Examine. Walk in Slide T-522, Rev A

1 Explore. Discover. Examine. Walk in Slide T-522, Rev A
This presentation provides an in-depth explanation of concepts which facilitate competent and safe use of the EZ-IO system. T-522, Rev A

to Successful Intraosseous Vascular Access
Clinical Principles to Successful Intraosseous Vascular Access Thank you for taking time to participate in Vidacare’s training program on the EZ-IO vascular access system. This program is designed to provide the practitioner with the key skills and knowledge to be competent inserting the EZ-IO Needle Set, while understanding the concepts of: Who needs an IO Determining the correct site Choosing the correct needle Placing the EZ-IO Caring for the patient Managing the EZ-IO Addressing pain control Monitoring the EZ-IO Removing the EZ-IO This program is designed to be used in concert with hands-on practice with the EZ-IO device, various needle sets and an array of simulation insertion aids such as synthetic bones of varying density. If at any time, you have a question that needs clarification , please contact the Vidacare Clinical Manager for your area; you can find contact information for your Clinical Manager at or by calling Expand Your Skills. Develop Your Practice T-522, Rev A

For adult and pediatric patients anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary situations The EZ-IO is a fast, safe and effective option for IV access in any patient. The EZ-IO is an immediate option that can serve as your primary line or a bridge to peripheral, PICC or CVL. T-522, Rev A

Icon Slide 4 The “5 Rights” – or key user reference points have expanded in 2012 to a new model using “6 Rights” or 6 key bullet points EZ IO users should consider when caring for any patient with an EZ-IO. T-522, Rev A

5 Icon Slide | Assess T-522, Rev A
There a several considerations to review during initial assessment of the patient for vascular access support needs. First – consider WHEN and WHAT is needed. T-522, Rev A

What to consider 6 When to use EZ-IO Rule out contraindications Other
Assess What to consider When to use EZ-IO Rule out contraindications Other considerations When to use the EZ-IO : EZ IO can be used for adult and pediatric patients anytime when vascular access is difficult to obtain in emergent, urgent or medically necessary situations (DFU). T-522, Rev A

When you need to give medications or fluids immediately
7 Assess | When to use IO When to use IO Shock Trauma Pediatric and Adult Shock Burns Drug overdose Rapid sequence intubation Post partum haemorrhage Cardiac Cardiac arrest Arrhythmia Myocardial infarction Congestive heart failure Chest pain Neurological Status epilepticus Stroke Coma Head Injury Respiratory Respiratory arrest Status asthmaticus Systemic Haemophiliac crisis Sickle Cell crisis Dehydration DKA (diabetic) End stage renal disease Dialysis When you need to give medications or fluids immediately The EZ-IO is an immediate option that can serve as your primary line or a bridge to peripheral, PICC or CVL. Clinicians should assess the patient and USE EZ IO when patients: Need very rapid access Have minimal risk factors (this will be discussed later in presentation) Need VA in less than 10 seconds to allow for proper pharmacology administration Require large fluid volume infusions This may include medical situations such as : Shock trauma Cardiac – resuscitation, arrhythmia, myocardial infarction, congestive heart failure, chest pain Hypothermia Neurological - status epilepticus, stroke, coma, head injury Respiratory - respiratory arrest, status asthmaticus Hematologic – systematic hemophiliac crisis, sickle cell crisis Metabolic crisis - DKA, diabetic shock Circulatory crisis – dehydration, end stage renal disease, dialysis T-522, Rev A

When IV access is difficult or impossible
8 Assess | When to use IO When to use IO Pre & Post Surgery Anesthesia IV Fluid Therapy Obesity Young & Old When IV access is difficult or impossible EZ-IO is a rapid way to gain vascular access and serve as a bridging device until long term VA is achieved in any of the box situations highlighted here. A common misunderstanding of how IO works is that it takes a LONG time for fluids, medications, or blood infused into the intraosseous space to reach the central circulation. This is false – scientific studies PROVE any fluid instilled into the intraosseous space gains access to the central circulation within just a few seconds.1 (Kramer) Kramer et al studied this at UTMB in Galveston, (2005) measuring peak serum concentrations of epinephrine and found that epinephrine infused via the intraosseous humeral site had an identical peak serum concentration compared to subclavian central line installation/infusion. So, you CAN USE EZ IO whenever IV access is difficult or emergently needed to provide care. Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparison of intraosseous proximal humerus and sternal routes for drug delivery during CPR. Circulation 2007; 116:II_993. 24Hour Placement Any Peripheral IV Drug T-522, Rev A

Assess | Rule out contra-indications
9 Slide Info This info does not print or project. Image Rights (L -R) Prosthesis Dreamtime RF Trauma to bone Dreamtime RF Landmarks Dreamtime RF Infection Dreamtime RF Recent IO Vidacare Assess | Rule out contra-indications Prosthesis Trauma to bone Rule out contraindications No Anatomical Landmarks Local Infection Recent IO in same bone (48 hrs) As part of completing the Assessment step; once the decision to use IO to gain access is made – assess the chosen site for any of the following 5 site contraindications for using EZ IO at that location: Prosthesis or previous orthopedic procedures near insertion site: The easy rule of thumb to use is if the patient has a surgical scar over a joint; assume there is a titanium appliance within the joint – and do NOT USE EZ IO at that location. Even though the EZ-IO Needle Sets are revolutionary, they cannot penetrate titanium. Simply move to another FDA-cleared insertion site and assess that site for use. Trauma or Fracture (in the targeted bone) - If there is a fracture (or suspected fracture) in the bone in which the EZ-IO is to be placed, an alternate site must be chosen. Fluid will follow the path of least resistance. When an IO is placed in a fractured bone, the fluid will leak or extravasate into the surrounding tissue through the fractured bone tissues. This can lead to complications including compartmental syndrome. IF a tibial fracture is suspected, both the proximal and distal sites will be contraindicated as they share the same common pathway inside the bone. However, if the patient has a fractured femur and an intact tibia, the tibial sites COULD be used as they are totally separate bones – the circulation from lower leg should be assessed to judge the appropriateness of using the lower extremity for EZ-IO the same as he or she would for any IV or femoral central line. Inability to locate landmarks (e.g. due to excessive tissue): If the clinician is unable to locate the landmarks for an insertion site for any reason (including excess adipose tissues), select an alternate insertion site where you can identify the boney landmarks. Infection at the insertion site: Vidacare does not recommend inserting the EZ-IO through an visible or documented infection or inflammed region at the insertion site. IO within past 48 hours (targeted bone): Healing from intraosseous insertion generally takes 48 hours and is defined as the point where another IO can be safely placed at the same anatomical site. By that time, fibrin formation and clotting are sufficient to prevent extravasation through the previous IO hole. Complete healing, to the point where X-ray can no longer detect the hole, usually takes several days or weeks. These 5 safety limitations are critical assessment considerations prior to insertion of an IO device. Miller LJ, Philbeck TE, Puga TA, Montez DF, Escobar GP. A pre-clinical study to determine the time to bone sealing and healing following intraosseous vascular access. Ann Emerg Med 2011;58(4S):S240 (Research sponsored by Vidacare Corporation) T-522, Rev A

Assess | Other considerations
10 Assess | Other considerations Other considerations prior to IO Volume replacement Patient needs Pain receptiveness Age Physique Trauma to limbs Patient status Position of limbs Accessibility to IO site Ability to stabilize IO site Accessibility Ability to monitor IO site Ability to maintain patient safety Post Insertion Other considerations to review as part of assessment are: Volume Replacement: larger volumes can be infused via the humerus due to the fact it is not as dense as the tibia. Patient Status: The humerus is a less painful site, so if the patient is alert and awake, this is a preferred site. Age is important when assessing and deciding which site to use; as the pediatric humeral head may not be as easily identified in younger patients. Physique or body proportion - Larger needles will be needed to access sites if the patient is muscular or large, or extremely swollen (burn victims). Trauma to limbs – assess the sites for trauma or past surgical signs. DO NOT apply the EZ-IO into a site that has had major or prosthetic orthopaedic surgery as mentioned in previous slide. Please refer to the DFU enclosed with the driver. Accessibility- The situational setting may dictate which site you utilize based on disability, history and mechanism of injury and patient transportation challenges. One must consider if the IO site can be stabilized so the line is maintained securely. Post Insertion – Yes, pre insertion, the caregiver needs to think ahead to post insertion care. Can the EZ-IO be secured and monitored safely avoiding dislodgement or injury? An EZ IO line should be assessed and monitored frequently to ensure flow, site management or needle dislodgement due to patient movement or transportation. Lairet J, Bebarta V, Lairet K et al. A comparison of proximal tibia, proximal humerus, and distal femur infusion rates under high pressure (>300mmHg) using the EZ-IO intraosseous device on an adult swine (sus scrofa) model. Prehospital Emergency Care 2011;15(1):117 Philbeck TE, Miller LJ, Montez D, Puga T. Hurt so good; easing IO pain and pressure. JEMS 2010;35(9):58-69 T-522, Rev A

11 Icon Slide | Site T-522, Rev A
Now that you have assessed the patient and determined EZ IO is indicated – the second key “right” is determining the correct site. Now, let’s review the site decision considerations for EZ-IO insertion. T-522, Rev A

12 3 Sites, 6 Options Site selection Proximal Humerus Proximal Tibia
Preferred site for adults Optimal site for high flow and quick drug uptake Awake, responsive patients Less painful Proximal Tibia Unresponsive Unfamiliarity with other sites Unable to landmark other sites Site selection The EZ-IO is approved for insertion in 6 anatomical sites. These sites are the right and left proximal tibia, the right and left distal tibia, and the right and left proximal humerus. Do NOT place an EZ -IO in the sternum. Site selection, like patient selection is dependent on the absence of contraindications outlined in previous slides, ability to monitor and secure the site and site specific advantages are noted here (review from slide). Lets review the Humeral site for advantages Dependent upon: No previous IO in 48 hours Absence of contraindications Accessibility Ability to secure & monitor Distal Tibia Larger patient Unable to access other sites T-522, Rev A

Site | Proximal humerus
13 Site | Proximal humerus Proximal humerus Humerus Clavicle Greater Tuberosity Proximal Humerus insertion site Surgical Neck The greatest advantage of using the humeral site is anatomical flow rates. The close proximity of the greater tubercle of the humerus to the heart, ensures rapid infusion of medications into the central circulation. Flow rates average 5L per hour can be achieved using the humeral site. The next two slides outline HOW to LOCATE the site on the proximal humerus. First, choose the arm and isolate the humerus visually and using palpation. The proximal humerus insertion site is located directly on the most prominent aspect of the greater tubercle. Many clinicians cannot find the greater tubercle – here is how: Ensure that the elbow is adducted (close to the body) and the patient’s hand is pronated (resting on the abdomen over umbilicus). Slide thumb up the anterior shaft of the humerus until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm (depending on the patient’s anatomy) above the surgical neck is the insertion site. Adutt: Advance needle set approximately 1 cm after contact with bone/or after entry into medullary space; in humerus site, for most adults needle set should be advanced until catheter hub is flush with or against the skin.” Vidacare recommends the 45mm needle on patient’s >40 kg and for the proximal humerus. Pediatrics: Release trigger when sudden “give” or “pop” is felt, indicating entry into the medullary space. These two steps are illustrated in the next slide. Miller L, Philbeck T, Montez D, Puga T. A two-phase study of fluid administration measurement during intraosseous infusion. Ann Emerg Med 2010;56(3):S151 Philbeck TE, Miller LJ, Montez D, Puga T. Hurt so good; easing IO pain and pressure. JEMS 2010;35(9):58-69 (Research sponsored by Vidacare Corporation) T-522, Rev A

14 Site | Proximal humerus Locate Insertion Point Locate Surgical Neck This slide illustrates the proper arm placement for identification of the humeral head, surgical neck of humerus. Practice finding this site on the person next to you (if classroom setting); or demonstrate (facilitator). Press hard moving upwards Hand on Umbilicus T-522, Rev A

15 Site | Proximal humerus Angle of needle insertion Slight Downward Angle 45O Anterior Plane 45O from the anterior plane Identify insertion point Due to the anterolateral location of the proximal humerus– use the angle illustrated here when placing a EZ IO in the proximal humerus. Make sure these angles are considered when placing an EZ IO when patients are in less than ideal positions (trauma /field situations). The circular insertion target is fairly large as illustrated here – about the size of the pad of an adult thumb. Note: Vidacare recommends stabilization of the catheter using the EZ- stabilizer whenever the humeral site is used. Also, secure the arm in place whenever EZ IO needle is in place; to prevent movement and accidental dislodgement of the IO needle cannula. Additional Guidance 45mm needle recommended for adults Advance 1 to 2cm after ‘pop’ Use EZ-IO Stabilizer T-522, Rev A

16 Proximal tibia Site | Proximal tibia Femur Patella
Muscle Femur Patella (Knee Cap) Tibial Tuberosity (bony thickness below knee cap) Ligament Another access site is the proximal tibia. The proximal tibia insertion site is found by measuring approximately 2 cm or 2 finger breadths below the patella and approximately 1 cm or 1 fingerbreadth medial to the tibial tuberosity. This is illustrated on the next slide. Note: Flow rates ranging from 350 mL – 3300 mL per hour within pressures of 300 mmHg in the proximal tibia. Philbeck TE, Miller LJ, Montez D, Puga T. Hurt so good; easing IO pain and pressure. JEMS 2010;35(9):58-69. Research sponsored by Vidacare Corporation Tibia T-522, Rev A

17 Proximal tibia Patients above 40 kg Actual insertion sites located
Site | Proximal tibia Proximal tibia Patients above 40 kg 2 finger breadths or 2 cm from base of patella The measurements here are for adults or patients greater than 40 kg in weight. The tibial tuberosity is the bump below the patella at the epiphysis of the tibia. This bump is not palpable on infants and some small children as it becomes prominent with age and greater weight bearing/exercise resistance. The tibial tuberosity is not developed until around 2 years of age. The proximal tibia insertion site in pediatrics is approximately 3 cm or 2 fingerbreadths below the patella and approximately 1 cm medial to the tibial tuberosity (depending on patient anatomy). Pediatric landmarking is shown on next slide. Actual insertion sites located Anterior (front) view (Fingers on tibial tuberosities) T-522, Rev A

18 Proximal tibia Patients up to 39kg Palpate Tibial Tuberosity
Site | Proximal Tibial Proximal tibia Patients up to 39kg Palpate Tibial Tuberosity The pediatric insertion sites at the proximal and distal tibia are the same as those for adults. In small children, generally under the age of two, the tibial tuberosity may be difficult or impossible to locate. If the tibial tuberosity cannot be palpated, locate the distal aspect of the patella, move approximately 2 cm distal (depending on patient anatomy) and then medial to the flat aspect of the tibia. With all patients, minimal pressure should be placed on the driver during insertion. This is especially true with pediatric patients. With softer and smaller pediatric bones, special care must be taken during insertion to avoid excessive pressure and recoil. Recoil can occur when the clinician feels the lack of resistance upon entry into the medullary space and inadvertently pulls back on the driver. This recoil may displace the needle set from the medullary space. The EZ- Stabilizer is strongly recommended for the humerus site and pediatric patients. T-522, Rev A

If Tibial Tuberosity cannot be palpated
19 Site | Proximal Tibial Proximal tibia Patients up to 39kg If Tibial Tuberosity cannot be palpated Pinch the sides of the tibia bone between your fingers and isolate the proximal tibia. The slightly medial flat surface of the bone is where the IO should be inserted. T-522, Rev A

20 Distal tibia Site | Distal tibia T-522, Rev A
The final site which can be assessed and used for EZ IO insertion is the distal tibia. The distal tibia insertion site is located approximately 2 cm or 2 fingerbreadths proximal to the most prominent aspect of the medial malleolus (depending on the patient’s anatomy). Place one finger directly over the medial malleolus; move approximately 2 cm proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. Note: for pediatric patients, the distance is less. Midline of the bone T-522, Rev A

21 Icon Slide | Needle T-522, Rev A
We have covered Assessment, Site Selection and now you are ready to choose your needle to match the tissue requirements for each site. Lets discuss: T-522, Rev A

22 3 Needles 15 mm 25 mm 45 mm Needle | Needle sizes T-522, Rev A
3-39 KG 25 mm > 40 KG 45 mm > 40 KG To ensure success with the EZ-IO system, it is imperative you match the right needle to the patient/site. Palpate and identify which site you want to use. One misconception is that needles are available and separated by pediatric, adult or small/large sizes. Although weight of the patient is one of the criteria for needle selection, selecting the correct needle set is based primarily on the site selected and tissue depth overlying that patient’s specific insertion site. The EZ-IO system has three Needle Sets to choose from, all are 15 G cannulas made of surgical stainless steel. The pink needle is 15 mm in length The blue needle is 25 mm in length The yellow needle is 45 mm in length Clear, red needles are non-sterile training needles, and come in all three lengths describe and illustrated here. Training needles are not for human use. T-522, Rev A

Needle | Needle features
23 Needle | Needle features Black Mark 5mm 5mm With the needle attached to the driver, insert the needle through the skin until the tip rests against the bone at a 90 degree angle. Adult compact bone is, on average, 3 mm thick. Look at the needle to assure that you can visualize at least one black line above the surface of the skin. You must confirm visualization of a black line (at least 5mm of needle) above the surface of the skin prior to powering the EZ-IO driver into the bone. If you cannot see a black line, the needle set selected is too short to reach the correct depth within the medullary space. Remove the current needle set, discard and select a longer needle set. Do NOT power a needle that is too short into the patient or bone insertion site…this will create a hole and make the site unusable for a minimum of 48 hrs. T-522, Rev A

24 15 25 45 45 No Select next size up Yes Insert needle
Needle | Selection Thin tissue over bone site Moderate tissue over bone site Thick tissue over bone site Humerus bone site (Adults) 15 mm 25 mm 45 mm 45 mm Insert the needle tip through skin until bone felt Can the black 5mm mark be seen? This slide depicts a guide for matching tissue depth to needle sizes. No Select next size up or different site Yes Insert needle T-522, Rev A

25 To choose correct needle, assess skin depth
Needle | Selection To choose correct needle, assess skin depth Depress skin tissue with thumb to gauge depth Depth of tissue over the site selected is key to safe and effective use of EZ-IO. To measure the depth of tissue, simply depress your thumb or fingers to gauge the depth of soft tissues over the site as shown here. T-522, Rev A

NO YES 26 Too small, mark not visible Mark visible Needle | Selection
Pre Drive 5mm Black Mark Check Visible blood flash or aspirate No need to see mark post drive 25mm Needle Set 45mm Needle Set THIS SLIDE IS FOR (– duplicate – not needed for hidden)…. NOTES PAGES ONLY – HIDDEN FROM PRESENTATION VIEW NO Too small, mark not visible Needle not touching the cortex YES Mark visible Needle will then go through the cortex T-522, Rev A

Pre Drive 5mm Black Mark Check Visible blood flash or aspirate No need to see mark post drive 25mm Needle Set 45mm Needle Set The first step is to insert the needle all the way through the soft tissues to the outer periosteum. This can be done manually or using power. Then pause and check to see if there is a black line visible OUTSIDE the skin between patient and hub of the insertion needle. This is your final check before placing the needle in the patient’s bone. In the picture on the right (above) the 45 mm needle has then been driven into the medullary space of the bone or transverse through the bone cortex. The next slides review how to assemble the needle and driver to get to this step of insertion. NO Too small, mark not visible Needle not touching the cortex and hub on skin YES Mark visible Needle will then go through the cortex T-522, Rev A

Check Visible blood flash or aspirate No need to see mark post drive 25mm Needle Set 45mm Needle Set THIS SLIDE IS FOR NOTES PAGES ONLY – HIDDEN FROM PRESENTATION VIEW Needle is firm in the bone!!! NO Too small, mark not visible Needle not touching the cortex YES Mark visible Needle will then go through the cortex T-522, Rev A

– will discuss with Bob T….. New Proximal Humerus insertion video
“Need video of Egg. That is the most powerful tool. Go ahead and show the BIG and PYNG” – will discuss with Bob T….. New Proximal Humerus insertion video Egg Insertion Video This video portrays the precision, control, and gentleness of the EZIO vascular access system utilizing the thinnest most delicate object – a raw egg. T-430 Rev, G

Remove the needle cap Insertion T-522, Rev A
First, prep the insertion site with antiseptic swab and let air dry. Identify the needle size you want and open package. Prime the EZ-connect and attach the needle letting the magnet in the hub attach to the driver. Then, remove the safety cap from the needle using standard sharps precautions. Hold the driver w/needle attached in dominant hand and relax, the driver is going to do the work, minimal pressure is needed to transverse bone tissues. You are ready for the next slide. NOTE: in a unlikely event that the battery on the Driver fails, clinicians may manually insert the EZ-IO Needle Set. Remove the needle cap T-522, Rev A

Insertion of the EZ-IO Stabilize Extremity
Insert Needle Set through the skin at a 90 degree angle Assess for black line when touching the bone To insert the needle, stabilize the extremity with your non-dominant hand. Hold the needle over the exact location and angle you plan to insert with. Gently and BEFORE PULLING THE TRIGGER, insert the needle set through the skin until you feel the tip of the needle touch the outer surface of the humeral bone. Verify that you can see at least one of the black lines on the needle above the surface of the skin PRIOR to squeezing the trigger. Now, squeeze the trigger and apply gentle, steady pressure to insert needle. Let the driver cut through the cortex and continue to hold the trigger ON until you feel a change or loss in resistance, When you feel a decrease in resistance, stop drilling by immediately removing your finger from the trigger. NOTE: For ADULT patients – “drive” the needle all the way thru cortex and go until the needle is seated in patient fully with hub flush to skin. On adult patients you may insert the needle 1-2 cm after contact with bone or until the hub is flush with the skin. For PEDIATRIC patients, stop immediately when you feel the resistance change…leaving needle and hub visible if indicated…do not penetrate up to the hub. ALWAYS USE CARE to ensure you have selected the appropriate size needle set based on tissue depth and when inserting past the sensation of pressure change or loss of resistance. Detach the driver from the needle set by holding the hub with one hand and pulling the driver straight up in direction of needle – avoid moving the needle from side to side or pulling it back out. T-522, Rev A

After insertion, check…
32 Needle | Check After insertion, check… Firmly seated needle Flash of blood No leaking around site No sign of extravasation Secure using EZ Stabilizer Use EZ Connect EZ-IO wrist band placed After any insertion of EZ IO needle – check to ensure the needle is firmly seated in the bone. Remove stylet Apply stabilizer Attach primed EZ-Connect (prime with saline or 2% Lidocaine) Confirm seated securely in bone, attempt to aspirate, flush Assess for physiologic responses in patient accordingly Monitor site NOTE: Absence of blood or inability to withdraw aspirate at the catheter hub does not mean the insertion was unsuccessful. Site placement can also be confirmed by ability to administer pressurized fluids, and noting the pharmacologic effects of medication administration after flow is established. Once catheter placement has been confirmed, the site should be regularly re-evaluated for signs of extravasation, fluid leakage or any other signs that indicate the needle tip is no longer in the medullary space. Verify placement before each infusion to mitigate the possibility of extravasations and compartment syndrome. The EZ-IO must be removed within 24 hours after insertion regardless of the insertion site. T-522, Rev A

33 Icon Slide | Flush T-522, Rev A
This completes the first three steps of assessment, site confirmation and needle selection and insertion. The next section reviews the steps to establish IV flow using EZ IO. Note: No FLUSH NO FLOW - awake and alert patients will need pain medications PRIOR to flushing the line initially. The next section on comfort will review pain management on this topic. T-522, Rev A

34 Flush for flow IO space filled with thick fibrin mesh
Pressure flush to open mesh Flush can be painful Pressurized flow needed The intraosseous space is filled with bone marrow, which is held in place by a thick fibrin mesh network. In order to obtain maximum flow rates you must displace or flush the thick fibrin mesh from the area around the tip of the inserted needle in the bone marrow. Displacement occurs with a rapid 10mL flush of sterile, normal saline. At the start of the flush, resistance will be felt. This is the fibrin mesh being displaced. (This has been described as a similar sensation to pushing D50 or accessing a PICC line or vascular access port that has not been recently accessed). After a successful flush of normal saline, you may notice the resistance diminishes as the channels open up. Occasionally, patients may require more than one flush or if IO has been saline locked for a prolonged period another flush may be required to obtain maximum flow rates. Flow rates will require pressure to overcome the inherent blood pressure of the intraosseous space – so use of a pressure cuff or positive pressure pump will be needed. Adjust the pressure until the desired flow rate is achieved. Labs may be drawn off of the EZ-IO. Discard first 2 mL or use for cultures. See the published guide about laboratory analysis of specimens drawn through an IO line. References are available regarding flow rates, flush, CT dye in IO lines on bibliography /website. Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med 2010;134: Miller LJ, Philbeck TE, Montez DF, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med 2009;133:1628 (Reasearch sponsored by Vidacare Corporation) T-522, Rev A

Real-time Flow Rate Studies
These real-time flow rate studies demonstrate how quickly IV contrast infused into the medullary space is disseminated into the central circulation. The video on the left shows dye infused through the proximal tibia. It is rapidly absorbed into the popliteal and femoral vasculature. The video on the right shows how rapidly dye reaches the right atrium when instilled via the proximal humerus, again demonstrating direct correlation between subclavian and proximal humerus for infusion of fluids. Contrast infused in a caprine model for illustration. Results in humans may vary. Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparison of intraosseous proximal humerus and sternal routes for drug delivery during CPR. Circulation 2007;116:II_933. T-430 Rev, G

36 Maintain flow approx 1/3 arterial pressure
Flush | Flow Maintain flow Infusions should be pressurised for optimal flow approx 1/3 arterial pressure The pressure in the medullary space is a fraction of the patient’s mean arterial pressure. This is important to remember because the pressure outside the bone in the IV bag must be higher than the pressure inside the bone to achieve flow. Therefore, fluids or medications must be delivered under pressure to obtain maximum flow rates. Note* These assumptions are anecdotal, based on observations in an animal lab. They have not been confirmed or published. Medullary space pressure can stop flow Note* These assumptions are anecdotal, based on observations in an animal lab. They have not been confirmed or published T-522, Rev A

Flush 37 Alert Patient ? Analgesia Recommended
Yes No Analgesia Recommended Consider need for analgesia later Administer analgesia prior to flush Flush with 0.9% Saline 10ml Adults Up to 5ml Children May need to be repeated The EZ-Connect extension set should be primed with normal saline and may be primed with 2%Lidocaine without preservatives or epinephrine (cardiac Lidocaine) as prescribed. If labs are to be obtained , draw directly form the hub then attach the primed EZ-Connect. Reconfirm EZ-IO placement after labs are drawn. As a reminder, if the patient is responsive to pain the clinician may consider 2% Lidocaine without preservatives or epinephrine (cardiac Lidocaine) for anesthetic effect prior to the 10ml normal saline flush. Remember NO FLUSH, NO FLOW. If this step is omitted optimal flow rates will not be achieved. Review this pathway using slide above T-522, Rev A

38 Icon Slide | Comfort T-522, Rev A
Patient comfort is essential in optimal patient care. This section reviews pain management interventions to support EZ IO utilization. T-522, Rev A

39 Many procedures hurt... Comfort T-522, Rev A
Slide Info This info does not print or project. Image Rights (L -R) Dreamtime RF Comfort Many common and accepted medical procedures cause discomfort. Insertion of EZ IO needles into the intraosseous space may be uncomfortable initially and vary in the sites used. The next slide illustrates why IO insertion can hurt. Many procedures hurt... IM Injections | IV Cannula | Central Line Insertion | Sub-cut. Infusions | IO T-522, Rev A

Flush, Aspiration & Infusion
40 Slide Info This info does not print or project. Image Rights (L -R) Vidacare Comfort Pain sensors Pressure sensors Two causes of pain Pain receptors located in the bone cortex differ from those found inside the bone marrow. The pain the patient will experience is different from the infusion causing a diffuse, dull aching pressure sensation. So there may be two distinct types of pain reported during insertion or during IO usage. Additionally, the sites selected have different pain levels reported – this may be due to the differences in bone density and marrow size. The next slide describes which site is least painful. Insertion specific short duration Flush, Aspiration & Infusion general diffuse related to pressure T-522, Rev A

Proximal humerus less painful
41 Slide Info This info does not print or project. Image Rights (L -R) Vidacare Proximal Humerus Proximal Tibia Distal Tibia Proximal humerus less painful Comfort The Proximal Humerus has been reported repeatedly as being less painful and has higher flow rates compared to use of either the tibial sites. Philbeck TE, Miller LJ, Montez D, Puga T. Hurt so good; easing IO pain and pressure. JEMS 2010;35(9):58-69 (Research sponsored by Vidacare Corporation) T-522, Rev A

Administration Consider Local protocols Comfort T-522, Rev A
Local IO anaesthesia must be administered very slowly until the desired anaesthetic effect is achieved Consider Cardiac lidocaine for patients responsive to pain. (1) Give prior to IO flush. (1) Repeat doses may be needed for continued local anaesthesia. (1) Local protocols Physician must decide the appropriate anaesthetic & dose. Recommendations by Dr. Hixson on next slide. Slide Info This info does not print or project. Image Rights (L -R) Local Protocols Dreamtime RF Consider Dreamtime RF Medullary Space Vidacare Comfort Note: Physicians must authorize appropriate dosage range and medication titration (see Pain Management Bibliography M-220 for additional information). The amount of Lidocaine required to achieve pain relief in awake and responsive patients may vary based on individual differences and distracting injuries or conditions. Clinical correlation and judgment are required. Vidacare’s publication M-220 is an annotated bibliography of clinical research studies that address management of IO infusion pain and can be used as a resource for clinicians to determine appropriate dosage range and method of administration. Philbeck TE, Miller LJ, Montez D, Puga T. Hurt so good; easing IO pain and pressure. JEMS 2010;35(9): (Research sponsored by Vidacare Corporation) Hixson, Richard Pain Management Algorithm for IO insertion. T-522, Rev A

43 Comfort | Suggested analgesia administration If discomfort reoccurs
Flush the IO needle with up to 10 ml sodium chloride 0.9% over 5 seconds Responsive to pain? Exclude contra-indications to cardiac lidocaine Yes Inject or infuse fluids and medication under pressure as required (2) Monitor patient clinically. Consider additional monitoring as indicated Administer initial (higher) dose of IO lidocaine over 1 to 2 minutes (1) Consider repeating the subsequent (lower) dose of IO lidocaine at a maximum frequency of once every 45 min If discomfort reoccurs Flush the IO needle with up to 10 ml sodium chloride 0.9% over 5 seconds (2) Administer subsequent (lower) dose of IO lidocaine over 30 seconds (1) Lets review this flow chart for pain management Inject or infuse fluids and medication under pressure as required (2) Source: Dr Richard Hixson 2011 Please refer to reference sheet or visit T-522,RevA Disclaimer: Whilst every care has been taken to ensure that doses and recommendations are correct, the responsibility for final check must rest with the prescriber.© Dr Richard Hixson 2011, all rights reserved.

44 Now we have decided to use EZ IO, placed a line in a selected location and flushed, managed the patient to a level of comfort; what do you have to do to maintain this line? (next slide) T-522, Rev A

Site Needle Patient Flow 45 EZ-IO - What to monitor and record
Suggest adapting local policies for the management of IV cannula and CVC lines Site No leaking Limb perfusion Signs of: Extravasation Compartment Syndrome Infection Needle Is secure Is intact EZ Stabilizer is secure Connections are secure Patient No pain from IO infusion EZ-IO Band placed on patient Flow Pressurized Infusion (adults) Expected flow achieved Pharmacological effects Regular, periodic assessment is essential for safe vascular access management. As a general rule – do what you would normally do with a peripheral IV site in terms of assessment, site care, flow rate intervention and medication use. Verification of placement before each infusion is recommended. Ensure the site is intact on each assessment visit, needle is securely in place, patient identifiers are in place, the patient is comfortable and of course – the EZ IO is working optimally – expected flow rates and pharmacological impact. The EZ IO must be removed 24 hours from the time of insertion. Lets review how to disconnect and remove the needle. T-522, Rev A

Maintain axial alignment – DO NOT rock the syringe
EZ-IO Removal Maintain axial alignment – DO NOT rock the syringe Rotate syringe clockwise while pulling straight back Removal: Disconnect EZ-Connect tubing – counter-clockwise rotation Attach syringe to hub Loosen stabilizer so will pull off easily with removal of IO Stabilized extremity Turn clock wise and pull straight up. DO NOT rock back and forth Apply local pressure to site Bandage and monitor as would PIV site To remove the EZ IO, begin by clamping the EZ-Connect tubing. The tubing is removed with counter- clockwise rotations of the Luer lock. Any size syringe with a standard Luer lock tip can then be attached to the EZ IO needle hub and will act as a handle for removing the IO needle. Stabilize the patient’s extremity. The syringe that is attached to the IO hub is then rotated in a clockwise direction. This action releases the tight seal in the cortex. Continue rotating clockwise and pull straight out. It may take several rotations to remove the IO needle. Avoid rocking the needle. Bleeding at the IO site is anticipated to be minimal unless certain medications or medical conditions lead to increased bleeding. Local pressure at the site may be warranted in these circumstances. The site is cleaned with an approved skin antiseptic and in most cases only a simple adhesive strip or minimal dressing is required. T-522, Rev A Back the EZ-IO catheter out of patient while stabilizing the extremity. T-430 Rev, G

Cleaning and 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 A final word about care and maintence of the EZ IO Driver. The EZ IO driver is manufactured using a non-porous fluid resistant medical-grade plastic covering; however, it is not fluid proof. For cleaning purposes, the driver should never be submerged in any cleaning solution. The driver should be wiped clean with a moistened cloth or sprayed with an anti-microbial. Clean around the drive shaft with a cotton applicator and check to ensure that nothing has attached to the magnetic tip. The driver is then wiped dry, or left to air dry, inspected and returned to the carrying case. (The trigger guard may also be replaced if no carrying case is utilized to secure the trigger from accidental discharge/battery waste). Always dispose of all sharps and biohazard materials from intraosseous lines using standard biohazard practices and disposal containers. Refer to the EZ-IO DFU for a more detailed instructions. If your clinical environment requires sterilization the G3 Power Driver can be sterilized using the STERRAD 100S, NX Standard cycle, and 100NX Standard cycle. STERRAD® is a product of Advanced Sterilization Products, a Johnson and Johnson Company. T-522, Rev A

48 What we have covered T-522, Rev A Summary
This is the completed training program for EZ IO utilization. For additional information, contact your local sales rep, clinical manager or go to the website at T-522, Rev A

49 Wrist band 24 hour Emergency Line Web support Follow us
Clinical Support Wrist band All the info you need 24 hour Emergency Line Web support Feedback form Follow us Access via website Vidacare provides 24/7 live clinical support to our clinical partners utilizing our 800 hotline ( ) which is featured on our patient wristbands, in addition to our website ( Vidacare places tremendous value on direct clinical feedback, so we invite you to visit our website to gain the newest, cutting edge product information as well as provide us with your direct feedback on our products performance. T-522, Rev A

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