1. IO Access Slides Please use selection of slides as appropriate to support practical workshop The workshop is designed as a practical station and slides are to support Instructors Editing of slides to include those appropriate to device being used in practical station may be required May be used in projected or handout formats

2. Intraosseous (IO) Access

3. Objectives Discuss the indications & contraindications for insertion of an intraosseous catheter Participate in the safe insertion technique of intraosseous access Describe the selection & preparation of IO fluids & medications for resuscitation December 15December 15December 15 © Health Workforce Australia

4. IO Access Indications For patients anytime in which vascular access is urgent or medically necessary situations -Deteriorating patient situations -Prevention of cardiac arrest -Assist in medication delivery, fluid management and transfusion needs during cardiac arrest As an alternative when IV access is difficult to obtain in emergent situation Note: ILCoR 2010: “Delivery of drugs via a tracheal tube is no longer recommended – if IV access cannot be achieved, drugs should be given by IO route”

5. IO Access Indications Administration of emergency drugs and fluids Flow rates of up to 125ml/min Equal to IV medication delivery in efficacy/dosing IO should be considered early in vascular access emergencies Time critical 2 peripheral IV attempts then consider IO Temporising measure until more definitive access can be obtained Alternate methods of vascular access have failed or not possible

6. IO Site Proximal Humerus Sternal Proximal Tibia Distal Tibia 6

7. Common Adult IO Landmarks Tibia – proximal & distal Some evidence suggests increased first attempt success Away from other management/procedures needed in resuscitation Proximal Humerus Gaining and retaining access in CPR may be difficult Sternal Gaining and retaining access in CPR may be difficult

8. Proximal Tibial Anatomy Many small veins lead from the medullary space to the central circulation

9. Contraindications Infection/burn at the insertion site Fractures at targeted bone Vascular injuries that may prevent reliable venous outflow Procedures to the bone selected for insertion Prosthetic joint, previous orthopedic procedures near insertion site Recent (24 hours) IO in same extremity Bone disease (e.g. osteoporosis, osteogenesis imperfecta) Unable to clearly identify insertion site Absence of anatomical landmarks or excessive tissue

10. Historic complications for most IO devices Extravasation Compartment syndrome Dislodgement Fracture Failure (Device or user in origin) Pain Infection (Osteomyelitis/Subcutaneous abscess)

11. Infusion of Medication Which Drugs can be given? Any medications that can be safely injected into a central venous catheter can be safely injected IO What Dose? IO and IV doses are identical Lab Testing: 10 – 15 ml of blood can be aspirated from an IO device and placed into a heparin-coated syringe for standard laboratory testing Bone marrow may be used reliably for venous biochemical and haematological analysis but not for venous blood gas tensions

12. Flushing 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 (or use of pressure infusion device) may be required to achieve maximum flow rate T-430 Rev, E

13. Insertion pain is reportedly equivalent to a large bore peripheral IV for conscious patients Infusion pain can be severe but is significantly moderated by the IO administering 20 – 40 mg Lignocaine Intraosseous access: is it painful?

14. Patella Tibial Tuberosity Insertion site Identify Landmarks

15. Location of Landmarks Place something under the knee (fluid bag/rolled towel) with the foot facing outward A.Find the first landmark/outset point: Tibial Tuberosity A rounded protrusion distal to the patella.

16. Location of Tibial Plateau From the Tibial Tuberosity B.Approx. 2 cm to the inner part of the leg to find a flat site This is the Tibial Plateau.

17. Location Injection Site From Tibial Tuberosity approx. 2 cm IN (inner leg) - Tibial Plateau. C.Then approx. 1 cm UP (toward patella) is target site

18. IO Devices Manual Hand trocar (Cook device) Impact Stored Energy (e.g. spring) Driven Drill Follow manufacturer guidelines on appropriate device choice, sizing and insertion and local policy and procedure

19. Confirm and Clean Insertion Site Use sterile gloves with an aseptic technique and a sterile needle Clean the skin Placing a bone marrow needle without using a sterile technique increases the risk of osteomyelitis and cellulitis

20. EZ-IO Access

22. Insert AD needle set into appropriate site Don’t force the needle set into position - “allow the driver to do the work” Position the EZ-IO Driver at a 90 degree angle to the bone Remember “EZ does it” 40 kg and greater usage Lightly holding the EZ-IO driver will improve usage

23. User induced recoil may lead to needle set dislodgement or extravasation STOP WHEN YOU FEEL THE POP Recoil! Caution! Allow driver to do the work! DO NOT EXCESSIVE FORCE Gently GUIDE needle set into position Important needle set insertion tip

24. Remove stylet and confirm placement Confirm placement by noting Blood at the stylet tip Firmly seated catheter Blood in the catheter hub Aspiration of blood Fluids flow without difficulty Pharmacologic effects Monitor the insertion site and distal extremity for signs of extravasation

26. Syringe flush the catheter with 10 – 20 ml of a sterile solution Syringe flush catheter No Flush = No Flow

27. Avoid rocking the EZ-IO catheter during usage EZ-Connect supplied with the needle set may provide additional stability

28. Begin infusion with pressure A pressure bag, infusion pump or syringe will improve the flow rates Medications may be deliverer in side arm of infusion line

29. Bone Injection Gun (BIG) Choose correct device Red = paediatric Blue = Adult Adult Set site for use on device

30. Setting Insertion depth Adjust blue barrel to determine depth of cannula insertion according to insertion site Proximal tibia Malleolus (distal tibia) Distal radius Proximal tibia setting applies for anterior humerus Clean site in preparation for insertion

31. Positioning With one hand holding firmly, Position the BIG At a 90 degree angel to the surface of the skin. *use aseptic technique throughout

32. Removal of Safety Latch With one hand holding the BIG firmly, pull out the safety latch by squeezing its two sides together Best done on target site to prevent incident from accidental misfire *Do not discard, it will later be used.

33. Important The red safety latch is NEVER removed before the B.I.G. is correctly positioned at the insertion site Do not discard the safety catch Used to stabilise cannula following insertion

34. Triggering While continuing to hold the bottom part firmly against the leg Place 2 fingers of your other hand under the ‘winged portion’ and the palm of that hand on the top Trigger the BIG by gently, but firmly pressing down Note: Extra force is not required

35. Stylet trocar Gently pull the stylet free holding the cannula in place Remove the stylet trocar Only Cannula remains in the bone.

36. Fixation The safety latch provides additional Stability May be completed prior to removing stylet

37. Aspiration Venous blood can be aspirated into a syringe for laboratory sampling Note: Lack of blood return does not mean the IO is improperly placed

38. Flushing Flushing 10-20ml of saline is recommended before the injection of fluids or drugs In conscious patients - consider local anaesthesia prior to administering fluids

39. Administration Fluids and drugs may now be administered A pressure infusion cuff may be required Optional : Connect a stopcock to the cannula and then use a standard I.V set

40. Removal of IO Devices Planned Device not to remain in situ for greater than 24 - 48 hours Only consider once alternate vascular access established Remove IV extension set from IO Deflate any pressure infusion devices first Document removal

41. Removal Attach empty 5 or 10 ml leuer lock syringe which will act as handle or per manufacturer’s instructions Maintain a 90 degree angle to site, rotate IO needle with syringe and gently pull IO out Hold direct pressure on site until haemostatis achieved Cover site with self adhesive dressing Monitor site for bleeding and signs of infection

42. EZ-IO Removal Maintain a 90 degree angle Maintain 90 degree angle, Rotate clockwise and gently Pull

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

44. Once catheter has been removed – cover site and monitor patient according to local policy and guidelines Post Removal

45. Any questions?

46. Summary Consider IO insertion when immediate access required & IV unsuccessful All fluids & drugs can be given via IO Laboratory tests can be sent, but tell the lab it’s marrow Insertion site is the antero-medial surface of the tibia

47. Advanced Life Support Course Slide set All rights reserved ©Australian Resuscitation Council and Resuscitation Council (UK) 2010; updated 2013