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Explore. Discover. Examine.
Clinical Principles
to Successful
Intraosseous Vascular
Access
Expand Your Skills. Develop Your Practice
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For adult and pediatric patients
anytime in which vascular access
is difficult to obtain in emergent,
urgent or medically necessary
situations
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Assess
What to consider
When to use
EZ-IO
Rule out
contraindications
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Other
considerations
Assess | When to use IO
When to use IO
When you need to give medications or fluids immediately
Shock
Trauma
Pediatric and Adult
Shock
Cardiac
Neurological
Respiratory
Systemic
Cardiac arrest
Status epilepticus
Respiratory arrest
Haemophiliac crisis
Arrhythmia
Stroke
Status asthmaticus
Sickle Cell crisis
Myocardial infarction
Coma
Dehydration
Congestive heart
failure
Head Injury
DKA (diabetic)
Burns
Drug overdose
Rapid sequence
intubation
End stage renal
disease
Chest pain
Post partum
haemorrhage
Dialysis
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Assess | When to use IO
When to use IO
When IV access is difficult or impossible
Pre & Post
Surgery
Anesthesia
IV Fluid
Therapy
Obesity
24Hour
Placement
Any Peripheral
IV Drug
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Young & Old
Assess | Rule out contra-indications
Rule out contraindications
Prosthesis
Trauma to
bone
No
Anatomical
Landmarks
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Local Infection
Recent IO
in same bone
(48 hrs)
Assess | Other considerations
Other considerations prior to IO
Patient needs
Patient status
Accessibility
Post Insertion
Volume replacement
Pain receptiveness
Position of limbs
Age
Accessibility to IO site
Ability to monitor IO
site
Physique
Ability to stabilize IO
site
Ability to maintain
patient safety
Trauma to limbs
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Site
3 Sites, 6 Options
Proximal Humerus
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
Dependent upon:
No previous IO in 48 hours
Absence of contraindications
Distal Tibia
Larger patient
Unable to access other sites
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Accessibility
Ability to secure & monitor
Site | Proximal humerus
Proximal humerus
Proximal Humerus
insertion site
Clavicle
Greater
Tuberosity
Surgical Neck
Humerus
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Site | Proximal humerus
Locate
Insertion Point
Locate
Surgical Neck
Press hard
moving
upwards
Hand on Umbilicus
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Site | Proximal humerus
Angle of needle insertion
Slight
Downward
Angle
45O from the
anterior
plane
45O
Anterior Plane
Identify insertion point
Additional Guidance
45mm needle recommended for adults
Advance 1 to 2cm after ‘pop’
Use EZ-IO Stabilizer
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Site | Proximal tibia
Proximal tibia
Muscle
Femur
Patella
(Knee Cap)
Tibial Tuberosity
Ligament
(bony thickness below knee cap)
Tibia
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Site | Proximal tibia
Proximal tibia
Patients above 40 kg
2 finger breadths
or 2 cm from
base of patella
Actual insertion
sites located
Anterior (front) view
(Fingers on tibial tuberosities)
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Site | Proximal Tibial
Proximal tibia
Patients up to 39kg
Palpate Tibial
Tuberosity
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Site | Proximal Tibial
Proximal tibia
Patients up to 39kg
If Tibial Tuberosity
cannot be palpated
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Site | Distal tibia
Distal tibia
Midline of the bone
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Needle | Needle sizes
3 Needles
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15 mm
3-39 KG
25 mm
> 40 KG
45 mm
> 40 KG
Needle | Needle features
Black Mark
5mm
5m
m
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Needle | Selection
Thin
Moderate
Thick
Humerus
tissue over
bone site
tissue over
bone site
tissue over
bone site
bone site
(Adults)
15
25
45
45
mm
mm
mm
mm
Insert the needle tip through skin until bone felt
Can the black 5mm mark be seen?
No
Select next size up
Yes
Insert needle
or different site
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Needle | Selection
To choose correct needle, assess skin depth
Depress skin tissue with
thumb to gauge depth
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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
NO
YES
Too small, mark not visible
Mark visible
Needle not touching the cortex
and hub on skin
Needle will then go through the cortex
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Egg Insertion Video
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Insertion
Remove the needle cap
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Insertion
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
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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
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Flush
Flush for flow
IO space
filled with
thick fibrin
mesh
Pressure
flush to
open mesh
Flush can
be painful
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Pressurized
flow needed
Real-time Flow Rate Studies
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Flush | Flow
Maintain flow
approx 1/3 arterial pressure
Medullary space pressure can stop flow
Infusions should be pressurised for
optimal flow
Note* These assumptions are anecdotal, based on observations in an animal lab. They have
not been confirmed or published
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Flush
Yes
Alert
Patient
?
Analgesia
Recommended
No
Consider need for
analgesia later
Flush
with 0.9% Saline
Administer analgesia
prior to flush
10ml
Adults
Up to 5ml Children
May need to be repeated
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Comfort
Many procedures hurt...
IM Injections | IV Cannula | Central Line Insertion | Sub-cut. Infusions | IO
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Comfort
Pain sensors
Pressure sensors
Two causes of pain
Insertion
Flush, Aspiration
& Infusion
specific
short duration
general
diffuse
related to pressure
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Proximal humerus
less painful
Proximal Humerus
Comfort
Proximal Tibia
Distal Tibia
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Comfort
Administration
Consider
Local protocols
Local IO anaesthesia must be
administered very slowly until
the desired anaesthetic effect
is achieved
Cardiac lidocaine for patients
responsive to pain. (1)
Physician must decide the
appropriate anaesthetic &
dose.
Give prior to IO flush. (1)
Repeat doses may be needed
for continued local
anaesthesia. (1)
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Recommendations by
Dr. Hixson on next slide.
Comfort | Suggested analgesia administration
Responsive to pain?
Flush the IO needle with up to 10 ml
sodium chloride 0.9% over 5 seconds
Yes
Exclude contra-indications to cardiac
lidocaine
Inject or infuse fluids and medication
under pressure as required (2)
Monitor patient clinically. Consider
additional monitoring as indicated
If discomfort reoccurs
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
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)
Inject or infuse fluids and medication
under pressure as required (2)
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Source: Dr Richard Hixson 2011
Please refer to reference sheet or visit www.pawz.net
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.
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Monitor
EZ-IO - What to monitor and record
Suggest adapting local policies for the management of IV cannula and CVC
lines
Site
Needle
Patient
Flow
No leaking
Is secure
Limb perfusion
Is intact
No pain from IO
infusion
Pressurized
Infusion (adults)
Signs of:
EZ-IO Band
placed on patient
Expected flow
achieved
Extravasation
EZ Stabilizer is
secure
Compartment
Syndrome
Connections are
secure
Infection
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Pharmacological
effects
EZ-IO Removal
Maintain axial alignment –
DO NOT rock the syringe
Rotate syringe clockwise
while pulling straight back
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Back the EZ-IO catheter out of patient while stabilizing the extremity.
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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
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Summary
What we have covered
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Clinical Support
Wrist band
24 hour
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