1. Review of Current Intraosseous Infusion Devices
4/23/2017
Review of Current Intraosseous Infusion Devices
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2. Lecture Outline
Review relevant anatomy, indications, & contraindications
Present background reasons for interest in expanding use of intraosseous (IO) line insertion in adults
Describe the insertion procedure for the 4 types of currently approved IO devices

3. 4/23/2017
Relevant Anatomy
Thousands of small veins lead from the bone medullary space to the general circulation
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4. 4/23/2017
Anatomy of long bones
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5. 4/23/2017
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6. Intraosseous (IO) Pressure and Flow Rates
4/23/2017
Intraosseous (IO) Pressure and Flow Rates
With a pressure bag or IV pump, Intraosseous (IO) flow rates are similar to IV’s through a 21-gauge needle.
Rate of infusion that can be given IO under 300 mm pressure :
2 to 50 cc / min (average 10 cc / min)
120 to 3,000 cc / hour (average 600 cc / hour)
Unit of blood in about 30 minutes
Rate of infusion that can be given IO under 1 meter gravity :
1 to 15 cc / min (average 4 cc / min)
Unit of blood in about 60 minutes
Unit dose injections can be given in seconds (5cc in 3 sec)
Rapid 10 cc syringe bolus dramatically increases IO flow rates
If no flush ---- there may be no flow !
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7. 4/23/2017
Intrinsic IO Pressure
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8. IO Infusion of Medication
4/23/2017
IO Infusion of Medication
Which Drugs can be given ?
Any medications that can be safely injected into a peripheral IV can likewise be safely injected IO
Caution with cytotoxic drugs and hypertonic saline
What Dose ?
IO medication doses are the same as those for IV injection
Flow rates (Rapid 10 cc bolus must be given first) :
To maintain optimal flow, pressure of 300 mm Hg must be applied to the infusion bag or the pump
Testing :
5 cc of blood can be aspirated from an IO device and placed into a heparin-coated syringe for standard laboratory testing
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9. Potential IO Complications
4/23/2017
Potential IO Complications
Extravasation (leakage)
Dislodgement
Compartment syndrome
Fracture of the bone
Failure
Pain (more about this on next slide)
Infection
Experience in thousands of children and reports on 4,000 adults show the infection rate to be less than 0.6 % and those infections are usually not serious (can be treated as outpatients with removal of device)
Mortality from above complications : None
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10. Pain from IO Insertion 85 % of IO patients will be unconscious
4/23/2017
Pain from IO Insertion
85 % of IO patients will be unconscious
For them, pain is not an issue
For the conscious patient : pain is an issue
Pain related to insertion of needle : Minimal
May numb the skin and periosteum with local xylocaine
Pain related to infusion of meds / fluids (visceral pressure)
Numb the vessels by injecting xylocaine 10 mg IO
Psychological anxiety : “You are going to do what ?”
Talk to your patient first
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11. Related to IO Insertion
4/23/2017
Two Kinds of Pain
Related to IO Insertion
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12. IO Contraindications Local Infection
4/23/2017
IO Contraindications
Local Infection
Major trauma to extremity : fractures in same limb
Prosthesis
Recent (24 hours) previous IO
Vascular compromise : diabetic leg (relative contraindication)
Absence of anatomical landmarks
Osteogenesis Imperfecta
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13. IV access is often difficult or impossible in these situations.
4/23/2017
IO Indications
Cardiac arrest
Status epilepticus
Shock / Trauma
Arrhythmia
Dehydration
Burns
Drug overdose
DKA (diabetic)
End stage renal disease
Stroke
Myocardial infarction
Coma
Head Injury
Anaphylaxis
Congestive heart failure
Dialysis
Emphysema
Respiratory arrest
Hemophiliac crisis
Sickle Cell crisis
Pediatric shock
Chest pain
IV access is often difficult or impossible in these situations.
IO is the Answer !
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14. Anatomic Sites for IO Insertion
Just below and medial to tibial tubercle (preferred site for both children and adults)
Lower anterior femur (for children)
Alternative sites for adults :
Ankle medial malleolus
Anterior humeral head
Sternum
Patella

15. Current IO State-of-the-Art
4/23/2017
Current IO State-of-the-Art
Universally taught as a core skill to :
Paramedics
Emergency physicians
Emergency and Pediatric Nurses
Used as a rescue IV access port in pediatrics
Current Standard of Care for children
So far only used sporadically in adults
New groundswell of interest for adults in past year
New ACLS, PALS, ATLS, ENPC guidelines recommend adult IO for difficult vascular access
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16. The IO Paradigm is Changing
4/23/2017
The IO Paradigm is Changing
No adult devices : New adult IO devices have been FDA approved.
Fear : 15 years experience in children has dispelled the fear of penetrating someone’s bone.
Infection : Infection has not been a problem.
Pain : Pain is controllable.
Difficult : New devices make the procedure easier than starting an IV.
No Support : Strong support from military, EMS, ER, ACLS.
Now the “Standard of Care” : PALS, ACLS, Military .
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17. American Heart Association : 2003 ACLS Principles & Practice
4/23/2017
New IO Mandate
“The use of IO devices is a promising technique to establish emergency access in adult patients” .
American Heart Association : 2003
ACLS Principles & Practice
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18. Military Interest in IO’s
4/23/2017
Military Interest in IO’s
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19. IV’s Are Difficult in Military Situations
4/23/2017
IV’s Are Difficult in Military Situations
Battlefield conditions
Darkness with use of night vision equipment
Hot or cold environments
Stressful : bullets flying overhead
Ratio of medics to troops : 1 to 40 or higher
Medic has to carry everything he needs in his rucksack (50 kg limit)
Training & experience
Medics are generally well trained
But have little opportunity for experience until actually needed
Is civilian prehospital trauma care any different ?
IV’s are just as difficult
Many of the same factors apply
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20. For 10 casualties it could take 2 hours to start IV’s
4/23/2017
Unnecessary Deaths
Acute hemorrhage is the major cause of Battlefield Mortality
50 % are killed immediately
50 % die within 1 hour of injury
Improvement in care requires
Control of bleeding
Rapid IV administration of blood & fluids
Most serious casualties go into shock
Veins collapse making IV access difficult
Average time for a medic to start an IV = 12 minutes
Average success rate in battlefield conditions = 30 %
For 10 casualties it could take 2 hours to start IV’s
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21. National Academy of Sciences Institute of Medicine, 1999
4/23/2017
National Academy of Sciences
Institute of Medicine, 1999
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22. F.D.A. Approved IO Devices
4/23/2017
F.D.A. Approved IO Devices
Jamshidi / Illinois Sternal / Cook (manually pushed in) needles
Mostly used for pediatrics
F.A.S.T. Pyng (Bed of Nails)
Designed for adult sternum
Manually inserts 10 needles at once
B.I.G. Bone Injection Gun (Nail Gun)
Shoots a needle into adult tibia and other bones
EZ-IO (Battery Powered Drill) by VidaCare Company
Powers a hollow drill (Catheter) into the medullary space
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23. Manually Inserted IO Needles
4/23/2017
Manually Inserted IO Needles
Manually inserted hand held infusion needles have been available for years.
Mostly used for infants because their bones are soft.
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24. 4/23/2017
PYNG (F.A.S.T.) IO Device
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25. F.A.S.T. Insertion Procedure
4/23/2017
F.A.S.T. Insertion Procedure
Do not attempt to use the F.A.S.T. 1 system unless you have been formally trained, evaluated, and authorized to perform this procedure !
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26. F.A.S.T. Insertion Procedure
4/23/2017
Undo or cut shirt to expose sternum.
Prepare the area of the manubrium with the iodine and alcohol swabs included in the package : wipe the area 1” below the sternal notch.
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27. F.A.S.T. Insertion Procedure
4/23/2017
Remove top half of backing labeled 1.
Place index finger in patient’s sternal notch ; the locating finger must be perpendicular to the manubrium.
Align Patch notch with patient’s sternal notch.
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28. F.A.S.T. Insertion Procedure
4/23/2017
Secure first half of the patch by pressing firmly downward, engaging the adhesive.
Reaching under the Patch, remove backing labeled 2 and press Patch to skin.
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29. F.A.S.T. Insertion Procedure
4/23/2017
Verify location : check that the locating notch matches the sternal notch and that the Target Zone is over the manubrium.
This is critical for safe and effective placement of the device.
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30. F.A.S.T. Insertion Procedure
4/23/2017
Remove Sharps Cap from the introducer ; the clear plastic Sharp Cap can be removed by slightly twisting and pulling away.
Place the bone probe cluster in the target zone with its long axis PERPENDICULAR (90 DEGREES) TO THE SKIN.
Ensure needle cluster is within the target zone.
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31. F.A.S.T. Insertion Procedure
4/23/2017
Press the Introducer into the target zone with firm and increasing force, until a distinct release of the Introducer handle is heard and felt.
The force must be applied in line with the long axis of the Introducer ; the forearm and elbow must be in line with Introducer’s axis.
After release pull straight back to remove the Introducer. 14 15
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32. F.A.S.T. Insertion Procedure
4/23/2017
Attach the right-angle female connector to the infusion tube.
16. 17
Attach syringe to straight female connector and withdraw marrow into the Infusion Tube to verify successful placement.
Remove and discard syringe. 18
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33. F.A.S.T. Insertion Procedure
4/23/2017
19.
Place the protector dome over the patch and press down firmly to engage the velcro fastening.
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34. F.A.S.T. Removal Procedure
4/23/2017
F.A.S.T. Removal Procedure
Remove the Protector Dome from the Target Patch.
Disconnect the Infusion Tube from the right angle female connector on the Patch.
Do not pull on the infusion tube to remove it ! 20 21
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35. F.A.S.T. Removal Procedure (Continued)
4/23/2017
F.A.S.T. Removal Procedure (Continued) 1
Insert the Remover into the Infusion Tube : keep the Infusion Tube straight out (90 degrees) from the patient.
Advance the remover till you hear or feel it enter the threads in the proximal tip of the infusion tube.
Turn the remover clockwise until it stops.
Pull straight out on the remover to remove the infusion tube. 2 3 4
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36. The B.I.G™ IO Device Pediatric B.I.G : 18 Gauge Adult B.I.G : 15 Gauge
4/23/2017
The B.I.G™ IO Device
Pediatric B.I.G : 18 Gauge
FDA Approved
Adult B.I.G : 15 Gauge
FDA Approved
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37. B.I.G. Technique of Insertion
4/23/2017
B.I.G. Technique of Insertion
Use a povidone iodine tincture sponge to clean the selected site for injection.
Position the front of the B.I.G™ at the selected site, holding and pushing firmly on the rear of the instrument.
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38. B.I.G. Insertion Sequence
4/23/2017
B.I.G. Insertion Sequence 1 . 4 2 5 3
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39. B.I.G. Technique of Insertion
4/23/2017
B.I.G. Technique of Insertion
Position the BIG with one hand to the site
and pull out the Safety Latch with the other hand.
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40. B.I.G. Technique of insertion
4/23/2017
B.I.G. Technique of insertion
Trigger the BIG at 90º to the surface.
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41. B.I.G. Technique of Insertion
4/23/2017
B.I.G. Technique of Insertion
Remove the BIG.
Pull out the stylet (trocar).
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42. Technique of insertion
4/23/2017
Technique of insertion
Connect IV Set with a stopcock and flush with 1 mg / kg for IO local anesthetics.
Fix the cannula with the Safety Latch.
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43. The “EZ-IO” Drill Device
4/23/2017
The “EZ-IO” Drill Device
“Making difficult IV access
a thing of the past”
Jointly owned and developed by
The University of Texas Health Science Center
&
VidaCare Corporation
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44. Univ. of Texas in San Antonio
4/23/2017
Univ. of Texas in San Antonio .
Dr. Larry Miller who developed the EZ-IO device
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45. “A kinder - gentler way”
4/23/2017
EZ-IO Description
Establishes IO access simply & automatically
Uses a hollow drill to enter the bone
Small battery powered driver implants the needle
Enables immediate access for all drugs and fluids
Provides safe and easy IO access for adults
“A kinder - gentler way”
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46. EZ-IO needle and sheath
4/23/2017
Final Design
EZ-IO needle and sheath
The EZ-IO drill
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47. Use of the EZ IO drill in a pediatric patient

48. EZ IO needle placed in tibia

49. Connector tubing for the EZ IO

50. How Adult EZ-IO Infusion Benefits Emergency Medicine
4/23/2017
How Adult EZ-IO Infusion Benefits Emergency Medicine
Saves time
Takes less than 10 seconds
IV’s take an average of 8 minutes
One provider can treat multiple patients (Mass casualties)
Faster transport (less time on scene)
Improves throughput time (in the emergency department)
Can be started en route (less scene time)
Allows provider to handle other problems : i.e. airway, meds
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51. How Adult EZ-IO Infusion Benefits Emergency Medicine (cont.)
4/23/2017
How Adult EZ-IO Infusion Benefits Emergency Medicine (cont.)
Easy to Teach
Short learning curve
Technique can be taught in less than one hour
Easy to remember (skill retention)
High success rate builds confidence
Huge benefit for first responders with limited critical care exposure
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52. How Adult EZ-IO Infusion Benefits Emergency Medicine (cont.)
4/23/2017
How Adult EZ-IO Infusion Benefits Emergency Medicine (cont.)
Easy to Use
Large target area
High success rate (better than 97 %)
High retention of skill level
Intuitive procedure
Vastly easier than starting IV’s
May be used by Basic EMT’s
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53. How the EZ-IO Device Benefits Emergency Medicine
4/23/2017
How the EZ-IO Device Benefits Emergency Medicine
Easy to Maintain
Rugged : designed for the emergency environment
Long shelf life
Replaceable AA batteries
Operates at wide temperature range
Easy to clean
Small storage space required
Replacement parts sent overnight (24 hour support)
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54. IO Summary Venous access in shock is often difficult or impossible
4/23/2017
IO Summary
Venous access in shock is often difficult or impossible
Thousands die because of lack of IV fluids & drugs.
IO has been used successfully for 65 years
The science behind it is solid ; its’ rationale is sound.
Inside the bone is a huge non-collapsible vein
Functions well in shock states.
Last 15 years in kids demonstrates IO to be Safe & Effective
Serious side effects are very rare (less than 1%).
IO has saved many children’s lives.
Currently IO is vastly underutilized in adults
IO should be considered first line treatment in serious illnesses for children and adults .
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55. 4/23/2017
IO Summary
We are witnessing a major paradigm shift in IO use for adults :
“With adult-IO, you no longer have to worry about time consuming and often exasperating IV access. You can now concentrate on the more important aspects of airway management, arrhythmias, fluid resuscitation, wound management and scene time” Larry Miller M.D .
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