1. Intraosseous Vascular Access

2. The System

3. EZ-IO Training Materials
PowerPoint™ Presentations
With comprehensive notes located behind each slide
EZ-IO StarCast Presentations
Quick Reference Card
Insertion & Removal Poster
Training Mannequins
Training Driver & Needle Sets
Complete Web Site
Clinical Support Hotline

4. The EZ-IO Lithium Driver
Sealed cap
Lithium
Batteries
Designed for 1000 human insertions

5. Needle set packaging

6. The EZ-IO Needle Sets Catheter & Stylet Specialized tip
EZ-IO Needle Set (safety cap removed)
EZ-IO Needle Set (“X-Ray View” with safety cap)
Stylet
Hub
Catheter & Stylet
Stylet
Needle Set
Safety Cap
Catheter &
Catheter Hub
Metal Disc

7. EZ-IO PD & EZ-IO AD needle sets
15 mm in length
5 mm mark
25 mm in length
Length and color are the only differences between PD & AD needle sets

8. Sealed Sterile Cartridge Open Cartridge Open Cartridge
Note: “lot code and expiration”
moved to cartridge barrel
Open Cartridge
Note: Needle Set’s position
Note: torn (and lifted) safety seal
Open Cartridge
Note: torn (and lifted) safety seal
Open Cartridge
Note: exposed “single use only” sticker
Stylet in “Shuttle”
Note: REMOVED safety seal
Stylet in “Shuttle”
Note: REMOVED safety seal

9. Put it where it belongs!
Stylets belong in approved sharps containers

10. Important EZ-IO usage considerations
Consider these points BEFORE EVERY EZ-IO insertion:
Did you “hear” a pop when the cartridge was opened?
Did the Driver easily attach to the Needle Set (With the Needle Set remaining in the cartridge)?
Did you REMOVE the Needle Set Safety Cap from the Needle Set?
Did you CONFIRM the 5 mm mark?
Needle Set
Note that a “lone Stylet” sits deeper than a complete Needle Set
Important EZ-IO usage considerations

11. Precise cylindrical hole created by EZ-IO insertion

12. The EZ-IO Infusion Solution
EZ-IO Storage Cases & Cradle
Training Driver
EZ-Connect
Wristband
Training Needle Sets
EZ-IO Driver
EZ-IO AD & PD Needle Sets

13. General IO Anatomy

14. Anatomy of intraosseous access
Thousands of small veins lead from the medullary space to the central circulation

16. Adult IO Anatomy

17. Proximal Tibial Anatomy

18. Distal Tibial Anatomy

19. The ankle joint is comprised of the Tibia, Talus and Fibula

20. Proximal Humeral Anatomy

21. Insertion site
Insertion site

22. Note that arm is adducted with the elbow posteriorly placed!
The Proximal Humerus insertion site is found “slightly anterior to the arms lateral midline”
Right arm
Adult male
Note that arm is adducted with
the elbow posteriorly placed!

23. Pediatric IO Anatomy

24. If the patient “fits” on the Broselow™ Tape THINK PINK
If the patient “fits” on the Broselow™ Tape THINK PINK* and use the EZ-IO PD =
*Obese pediatric patients may require the EZ-IO AD needle Set

25. Pediatric Anatomical Overview

26. The pediatric growth plate
Clearly visible
tibial growth plate
Growth Plate
Insertion site
Tibia
Right Leg
Left Leg

27. Identifying the EZ-IO PD insertion site
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
The Tibial Tuberosity can be difficult or impossible to palpate on younger patients

28. Identifying the EZ-IO PD insertion site
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
As patients mature the Tibial Tuberosity becomes easier to identify

29. Indications

30. Indications for intraosseous access
Cardiac Arrest
Respiratory Compromise
Need for immediate rapid sequence induction
Hemodynamic Instability
Mass Casualty Situations
Trauma Resuscitations
Bridge to Central Line
Allowing Controlled Placement
Altered Level of Consciousness
Difficult IV Placement
Intraosseous Access = Immediate Vascular Access

31. Indications for Intraosseous Access
Patients with poor peripheral access
Dialysis Patients
Sickle Cell Patients
Obese Patients
Mass casualty incidents
(shootings, motor vehicle collisions)
Congestive Heart Failure
Oncology Patients
IV Drug Abuse
Dehydration (especially pediatrics)
Diabetic Patient (DKA or hypoglycemia)
Consistent with the AHA & ERC Guidelines
Intraosseous Access = Immediate Vascular Access

32. AHA, ERC, ILCOR, NAEMSP Guidelines
IO should be considered early in vascular access emergencies
Adults - 2 peripheral IV attempts Progress to IO
Pediatrics - 1st line of choice
ET tube is no longer recommended for drug delivery
Central lines are discouraged
Approximately 5 million central venous catheters placed each year in US
Central line placement causes unnecessary drug delivery delay during resuscitation
CDC report indicates 9% infection rate with central lines in US
ILCOR is comprised of seven formal members – American Hear Association, European Resuscitation Council, Heart and Stroke Foundation of Canada, Australian and
New Zealand Committees on Resuscitation, Resuscitation Councils of Southern Africa, and the InterAmerican Heart Foundation and Resuscitation Council of Asia

33. What About Infections With IO
20 + year history in pediatrics with Cook/Jamshidi needles sets
Overall infection rate is 0.6%
Cases of osteomylitis occurred when catheter was left in place for > 72 hours
Newer IO devices cause less bone trauma
EZ-IO database
Contains insertions with no local infections or osteomylitis
Estimate of 80,000+ insertions with no local infections or osteomylitis

34. Intraosseous access: is it painful?
IO insertion pain is equivalent to a peripheral IV
IO infusion pain can be severe but is significantly moderated by the administration of 20 – 40 mg Lidocaine for patients > 39kgs and 0.5mg/kg for patients 39kgs or less via the IO route (*2% preservative free Lidocaine is recommended)

36. Pressure and Flow Rates
With pressure, IO flow rates are similar to IV
Tibial relates to a 18 gauge catheter
Humeral relates to a 16 gauge catheter
Flow rates for infusions given through an IO with a 300 mm pressure infuser
3 – 6 liters/hour of saline
Unit of blood in approximately minutes
Syringe bolus infusions can be completed in seconds
Initial rapid 10 cc syringe bolus for patients > 39kgs and 5cc flush for patients
39kgs or less dramatically increases IO flow rates
NO FLUSH = NO FLOW

37. 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:
cc of blood can be aspirated from an IO device and placed into a syringe for standard laboratory testing

38. The Reality of Intraosseous Flow
Immediate flow from the tibia and proximal humerus to the central circulation

39. Contraindications Local Infection (at the insertion site)
Fractures (to the bone selected for insertion)
Prosthesis
Recent (24 hours) IO in same extremity
Absence of anatomical landmarks or excessive tissue

40. EZ-IO Access
The art of insertion

41. Observe Body Substance Isolation Precautions

42. Adult

43. Confirm and clean insertion site

44. Confirm and clean insertion site

45. Identify the Proximal Humerus insertion site
Elbow should remain adducted
and posteriorly located
To begin the discussion on humeral access we must first position the arm for maximum proximal humerus exposure. Adduct the patient’s humerus then posteriorly locate the elbow to the same “plane” as the spine. Next, place the patient’s hand on the patient’s abdomen – at or near the umbilicus.
This position will provide for a more prominent insertion site as well as ensure protection for the vital neurovascular structures located under the patient’s arm.
Important note: By placing the hand on the umbilicus (rather than the entire forearm across the abdomen) you will be able to retain the elbow on the stretcher or the ground and maximize your approach to the proximal humerus.
Place the hand over the umbilicus
for humeral positioning and safety
orient the arm to this position

46. Preferred insertion site identification method
Place patient in supine position with the arm correctly oriented

47. Alternate site identification method
Coracoid Process
Acromion
This alternate method of identification can be used
in association with the preferred method to ensure proper placement
Alternate site identification method

48. Confirm and clean insertion site

49. Pediatric

50. Confirm and clean insertion site

51. Confirm and clean insertion site

52. Confirm and clean insertion site

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

54. Insert PD needle set into appropriate site
Position the EZ-IO Driver at a 90 degree angle to the bone
Lightly holding the EZ-IO driver will improve usage
kg usage
Select needle set based on patient size & weight

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

56. Confirm placement by noting
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

57. Syringe flush catheter
No Flush = No Flow
Syringe flush the catheter with 10 ml (5 ml for PD) of a sterile solution

58. Avoid rocking the EZ-IO catheter during usage
Use the EZ-Connect supplied with the needle set!

59. Begin infusion with pressure
kg usage
Regulate fluid delivery
for pediatric patients
40 kg and greater usage
A pressure bag, infusion pump or syringe will improve the flow rates

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

61. Once catheter has been removed – cover site and monitor patient

62. Possible Complications
Rocking, Bending or inadvertently Striking the catheter may cause it to break
If breakage occurs Grasp the exposed catheter with a hemostat – rotate and pull
24 hour emergency support

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