ez-io ad access tibial start up training · this vidacare ez-io® ad proximal tibial access...

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This Vidacare EZ-IO® AD Proximal Tibial Access Training Program is designed to

help you understand and use the EZ-IO® AD infusion system. Our collective goal at

Vidacare® remains rapid, safe, effective vascular access for all critical patients.

Vidacare’s approach to this goal is simple – the right equipment - in the best hands –

where it’s needed most.

Associated with this supplemental program is a complete training system. This

includes the Directions For Use (DFU’s), Training Manual, Quick Reference Card,

Insertion/Removal Poster and PowerPoint™ Presentations (“Start up” and “In Depth”

versions), Mannequins, Training Driver and Needle Sets, Complete Website with

instructor resource center and finally a 24 hour emergency support telephone line.

At the completion of this supplemental training program if you still have questions or

concerns please call us at 1.866.479.8500 or visit our website at www.vidacare.com

We at Vidacare® appreciate what you do and the time you devote to it. Thank you

for inviting us to be a member of your team!

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It has not been decided yet how needles will be replaced/restocked. TEMS is

working with local hospitals to do a one for one exchange.

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Listed here are the primary indications. Can you think of specific conditions that

would fit each indications?

Examples of disease states often meeting these criteria include, but are not

limited to the following:

Cardiac arrest, Status epilepticus, All shock states, Arrythmias, Dehydration

Burns, DKA (diabetic), Renal failure, Stroke, AMI, Coma,

OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema,

Respiratory arrest, Hemophiliac crisis

IO access is not appropriate for hypoglycemic diabetic patients because you can

manage those patients by other means – glucagon IM or D50 rectally (with

physician order). IO access is not appropriate for patients with suspected

narcotic overdoses because you may administer Narcan IM if you are unable to

obtain IV access.

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These are the contraindications.

Recent fractures may cause fluid or drugs to leak – thus not reaching target tissue and possibly causing additional significant injury.

Certain Orthopedic procedures at or near the insertion site. An example of an orthopedic procedure that would cause problems for the EZ-IO® would be a joint replacement. This would render the IO space inaccessible secondary to the indwelling device. Another example would be a recent (within the past 24 hours) IO placement in the same extremity. This “extra penetration” might allow extravasation (leakage) into surrounding soft tissue from the initial IO site. Not all orthopedic procedures pose a contraindication or concern to EZ-IO® usage.

Infections at the insertion site pose a risk because they could be introduced into the bone and systemic circulation.

Inability to locate the EZ-IO® landmarks could result in an attempted placement that is unacceptable and dangerous.

Lastly, Excessive tissue over the insertion site may result in the needle set failing to reach the intraosseous space.

With each of the contraindication listed above the provider should consider alternate appropriate sites. Additionally, a risk versus benefit assessment should always be considered prior to any IO placement.

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With this slide we can identify the structures of the tibia. Important points to note

include the thin cortex at the Epiphysis (Our EZ-IO® AD insertion site) versus the

thick compact bone on the Diaphysis. Note also the vasculature crossing

between the cancellous bone, through the thin cortex and into the veins – this

makes IO infusion possible!

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To begin the discussion on humeral access we must first position the arm

for maximum humeral head exposure. First, adduct the humerus then

posteriorly locate the elbow toward the back rest of your chair (or floor if

you are laying down). Next, place the patient’s forearm (more specifically

the hand) on the patient’s abdomen – at or near the umbilicus. This 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.

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The important anatomy of the proximal humerus is relatively easy to understand

and appreciate -

* provided that the model or patient is in a supine position (or at a

minimum leaning back in their chair - with shoulders against the back

rest) and the arm adducted with the elbow posteriorly located prior to any

palpation attempt.

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In these two images the provider can visualize the insertion site and the relative

lack of critical structures near that specific location.

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Providers may consider confirming the location of the intertubercular groove or

sulcus by laterally then medially rotating the forearm while palpating just

medially to the greater tubercle. This optional identification maneuver could be

performed if the operator had concern about the location of the greater tubercle

Note that following the bicep’s midline to the humeral head will also place you

directly over the sulcus.

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The patient should be in a supine position (or at a minimum the elbow

should be placed posteriorly six to eight inches). With the elbow posteriorly

placed (by gravity or effort) the humeral head becomes easily visible. Inability to

properly position the patient’s arm could lead to insertion failure.

Expose shoulder and adduct humerus (place the patient’s arm against the

patient’s body) resting the elbow on the stretcher or ground. (With the

patient in this position you may immediately note the humeral head on the

anterior-superior aspect of the upper arm or anterior-lateral shoulder).

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A 1. Expose shoulder and adduct humerus (place the patient’s arm against

the patient’s body) resting the elbow on the stretcher or ground. (With

the patient in this position you may immediately note the humeral head on

the anterior-superior aspect of the upper arm or anterior-lateral shoulder)

Note that the humerus has been outlined and clearly rests anterior to the

arms lateral midline.

Do not attempt insertion medial to the intertubercular Groove or the

Lesser Tubercle (Defined by the RED CIRCLE in the 3 D drawing).

Insertion medial to the Lesser Tubercle can injure nerves, arteries and

veins!

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This is the preferred method for locating the humeral head insertion site.

A 2. Palpate and identify the mid-shaft humerus and continue palpating

toward the proximal aspect or humeral head. As you near the shoulder you

will note a protrusion. This is the base of the greater tubercle insertion site.

A 3. With the opposite hand you may consider “pinching” the anterior and

inferior aspects of the humeral head while confirming the identification of

the greater tubercle. This will ensure that you have identified the midline of the

humerus itself.

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Once you have identified the greater tubercle - confirm the specific

insertion site by palpation of the greater tubercle’s outer margins ultimately

resting your finger on the most prominent aspect of that structure – the EZ-IO

AD insertion site.

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Patient should be in a supine position

B 1. Identify two land marks on the lateral shoulder consisting of the

acromion and the coracoid process. This can be accomplished by placing

one hand on the lateral superior aspect of the patient’s shoulder and palpating

for the protrusions. Identifying the coracoid process and the acromion can also

be accomplished by “walking” your index and middle finger along the clavicle to

the shoulder’s lateral end.

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B 2. Identify the greater tubercle insertion site approximately two finger

widths inferior to the coracoid process and the acromion. One can envision

the location of this site by creating a “triangle” - the upper portion of connecting

the coracoid process and the acromion while the “point” reaches inferiorly and

slightly anteriorly - approximately two finger widths along the midline (between

the coracoid and the acromion).

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B 3. This image shows the “two finger widths” distance to the insertion

site.

CAUTION – This alterative method does not take into account extremely

muscular individuals that might possess larger upper arm musculature.

Extreme caution should be exercised when utilizing this identification

technique.

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Once you have identified the greater tubercle - confirm the specific

insertion site by palpation of the greater tubercle’s outer margins ultimately

resting your finger on the most prominent aspect of that structure – the EZ-IO

AD insertion site.

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The patient should be in a supine position

A/B 1. Expose shoulder and adduct humerus (place the patient’s arm against the

patient’s body) resting the elbow on the stretcher or ground. Forearm resting on

the abdomen (With the patient in this position you may immediately note the proximal

humerus on the anterior-superior aspect of the upper arm or anterior-lateral shoulder)

A 2. Palpate and identify the mid-shaft humerus and continue palpating toward the

proximal aspect or insertion site. As you near the shoulder you will note a small

protrusion. This is the base of the greater tubercle insertion site.

A 3. With the opposite hand you may consider “pinching” the anterior and inferior

aspects of the humeral head while confirming the identification of the greater

tubercle. This will ensure that you have identified the midline of the humerus itself.

Alternatively:

B 2. Identify two land marks on the lateral shoulder consisting of the acromion and

the coracoid process. This can be accomplished by placing one hand on the lateral

superior aspect of the patient’s shoulder and palpating for the protrusions. Identifying the

coracoid process and the acromion can also be accomplished by “walking” your index

and middle finger along the clavicle to the shoulder’s lateral end.

B 3. Identify the greater tubercle insertion site approximately two finger widths

inferior to the coracoid process and the acromion (anterior to the arms lateral

midline) One can envision the location of this site by creating a “T” - the upper portion of

the letter connecting the coracoid process and the acromion while the “leg” reaches

inferiorly and slightly anteriorly - approximately two finger widths along the midline

between the two structures. Another way to envision this location is to create an inverted

triangle between the aforementioned structures.

Do not attempt insertion medial to the greater tubercle! (RED CIRCLE!)

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With this slide we can identify the structures of the distal tibia.

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With this slide we can identify additional structures of the distal tibia. Important

points to note include the thin cortex at the Epiphysis (Our EZ-IO® AD insertion

site) versus the thick compact bone on the Diaphysis.

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Here we can identify the major structures of the upper and lower leg as well as the

three EZ-IO® AD landmarks, the Tibia (anterior or most forward lower leg

bone), Patella (knee cap) and Tibial tuberosity (bump or raised area on the

anterior aspect or front of the tibia)

Note that the insertion site is one finger width medial to the tibial tuberosity.

Can you identify the landmarks on yourself or someone else?

Helpful reminders: “If you want to get in – think in!” (rational – If you want to get

inside (the IO space or bone) – think inside – (the medial aspect of the leg.)

“Big Toe – Go EZ-IO®” (rational – the EZ-IO® AD is placed on the medial

(inside) aspect of the leg – the Big toes are found on the medial (toward the

inside) aspect of the leg.

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Stabilize the leg and place the powered EZ-IO® AD - maintaining a 90 degree

angle during the insertion process.

IMPORTANT - Stabilize the needle set prior to any attempt at removing the

driver. Failure to stabilize the catheter may cause inadvertent dislodgment.

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Attach the EZ-Connect® extension set to the standard Luer lock & confirm placement of the

catheter. This can be accomplished by identifying several important findings:

• The catheter is firmly seated and does not move.

• Observed blood on the stylet tip (noted by wiping tip on a 4x4) prior to placing stylet in the

shuttle or bio hazard container.

• You note blood at the catheter hub.

• You are able to aspirate blood or marrow from the catheter (We recommend aspirating a small

amount of blood due to its extremely viscous nature).

• Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or

around the tissue. CAUTION: Conscious patients will experience pain with infusion prior to

Lidocaine! Flow rates may be slow or non existent prior to the 10 ml bolus.

• You note the effects of administered drugs.

• X-Ray confirmation.

Protect the sterile connection point on the catheter hub!

Four Important points to consider once the EZ-IO® AD has been established:

• Routinely reconfirm that the EZ-IO® catheter is secure and in position.

• Maintain appropriate protection at the insertion site guarding against accidental bumping or

dislodgement.

• Frequently monitor the EZ-IO®, the fluid and the extremity.

• Remove the EZ-IO® within 24 hours.

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Do not connect a syringe directly the EZ-IO® during treatment. Use of the EZ-

Connect® will help to avoid complications.

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* If you need a blood sample for lab analysis – we recommend drawing blood directly from the EZ-Connect® with a syringe. Be certain to adequately flush the tubing after the sample is obtained.

Prior to any drug or fluid administration be certain to Syringe flush the EZ-IO® catheter with 10 ml of fluid. NOTE: THERE IS A DISTINCT DIFFERENCE BETWEEN THE “SYRINGE FLUSH OR BOLUS” DESCRIBED ABOVE AND FLUID “GIVEN OR PUSHED WITH AN ADMINISTRATION SET”. This difference relates specifically to:

The pressures generated by the syringe – clearing the “pathway for treatment” (Which is necessary because of the anatomy and nature of the IO space) Versus the relatively slow, low pressure “supportive administration” of fluids given over time.

“NO FLUSH = NO FLOW” Failure to “syringe flush” may result in a limited or no flow IO situation

Ensure that you protect the patient and the sterile connection point on the catheter hub!

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Insure tube is flush.

Attach the EZ-Connect extension set to the standard Luer lock & confirm placement of the catheter. This can be accomplished by identifying several important findings.

1. The catheter is firmly seated and does not move.

2. You note blood at the catheter hub.

3. You are able to aspirate blood or marrow from the catheter (We recommend aspiration of only a small amount of blood due to its extremely viscous nature).

4. Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or around the tissue. CAUTION : Conscious patients will experience pain with infusion prior to Lidocaine! Flow rates may be slow or non existent prior to the 10 ml bolus.

• You may have checked the stylet tip for blood prior to placing it in the stylet shuttle or bio hazard container.

Other indicators of proper placement include:

• You may notice the effects of administered drugs

• X-Ray confirmation


Four Important points to consider once the EZ-IO AD has been established:

1. Routinely reconfirm that the EZ-IO AD catheter is secure and in position.

2. Maintain appropriate protection at the insertion site.

3. Frequently monitor the EZ-IO AD, the fluid and the extremity.

4. Remove the EZ-IO AD within 24 hours.

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Listed here are the primary indications. Can you think of specific conditions that

would fit each indications?

Examples of disease states often meeting these criteria include, but are not

limited to the following:

Cardiac arrest, Status epilepticus, All shock states, Arrythmias, Dehydration

Burns, DKA (diabetic), Renal failure, Stroke, AMI, Coma,

OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema,

Respiratory arrest, Hemophiliac crisis

If you are unable to obtain IV access on a hypoglycemic diabetic patient, you

should administer glucagon IM or rectal dextrose (with physician orders). If you

are unable to obtain IV access on a patient with a suspected opiate overdose,

you may administer Narcan IM.

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Let’s start with an anatomical overview. Here we identify the structures of the developing

tibia. Important points to note include the thin cortex at the Epiphysis (The EZ-IO® PD

insertion site) versus the thicker compact bone on the Diaphysis. Note also the

vasculature crossing from the cancellous bone, through the thin cortex and into the veins

– this makes IO infusion possible!

The growth plate is of particular interest with regard to pediatric intraosseous placement.

There is a great deal of discussion and a substantial body of evidence surrounding the

pediatric growth plate. The fear, though unproven, suggests that permanent injury may

result from the placement of an IO catheter into the growth plate. At present there are no

studies in the literature associating IO placement with growth plate injury.

Research in animal models suggests that inadvertent IO placement through the growth

plate does not cause any long term deformity or any other complications. Additionally,

follow up x-rays in pediatric patients, whose epiphyseal plates had been inadvertently

penetrated by IO needles, never demonstrated complications.

However, to be prudent you should always maintain a reasonable distance from the

growth plate to avoid it’s inadvertent penetration.

The following slides will assist you in the selection and confident placement of the EZ-IO®

PD in the correct anatomical location (with due regard for specific developmental

changes).

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The Broselow™ tape adds a straight forward decision making tool for the

EZ-IO® PD.

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This slide compares the EZ-IO® Needle Sets.

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Important: The tibial tuberosity is often difficult or impossible to palpate on very

young patients! For this reason - the EZ-IO® 3-12 kg (Infant) trainer does not have a

palpable tibial tuberosity! The traditional approach for IO insertions in small patients - where

the tibial tuberosity cannot be palpated - is to identify the insertion site -“TWO FINGER

WIDTHS BELOW THE PATELLA and then medial along the flat aspect of the TIBIA”.

On the other hand our EZ-IO® 13-39 kg (child) trainer does have a palpable tibial tuberosity

reflecting the natural growth process. The traditional approach to IO insertion in more mature

patients - where the tuberosity can be palpated - is “One finger width distal to the tibial

tuberosity along the flat aspect of the medial tibia”.

* Once the patients reaches maturity the most acceptable site for EZ-IO® AD insertions is

directly medial to the tibial tuberosity.

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Important: The tibial tuberosity is often difficult or impossible to palpate on

very young patients! For this reason - the EZ-IO® 3-12 kg (infant) trainer does not

have a palpable tibial tuberosity! The traditional approach for IO insertions in small

patients - where the tibial tuberosity cannot be palpated - is to identify the insertion

site -“TWO FINGER WIDTHS BELOW THE PATELLA and then medial along the

flat aspect of the TIBIA”.

On the other hand our EZ-IO® 13-39 kg (child) trainer does have a palpable tibial

tuberosity reflecting the natural growth process. The traditional approach to IO

insertion in more mature patients - where the tuberosity can be palpated - is “One

finger width distal to the tibial tuberosity along the flat aspect of the medial

tibia”.

* Once the patients reaches maturity the most acceptable site for EZ-IO® AD

insertions is directly medial to the tibial tuberosity.

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Here we can identify the major structures of the lower leg as well as the three EZ-

IO® PD landmarks, the Tibia (anterior or most forward lower leg bone), Patella

(knee cap) and Tibial tuberosity (bump or raised area on the anterior aspect or

front of the tibia) IF PRESENT.

Helpful reminders: “If you want to get in – think in!” (rationale – If you want to get

inside (the IO space or bone) – think inside – (the medial aspect of the leg.)

“Big Toe – Go EZ-IO®” (rational – the EZ-IO® PD is placed on the medial

(inside) aspect of the leg – the Big toes are found on the medial (toward the

inside) aspect of the leg.

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Hold the EZ-IO® Driver (with the appropriate Needle Set attached) lightly in your

dominate hand.

Stabilize the leg and gently place the EZ-IO® PD Needle Set - maintaining a 90

degree angle during the insertion process.

STOP- WHEN YOU FEEL THE POP

IMPORTANT - Stabilize the needle set prior to any attempt at removing the

driver. Failure to stabilize the needle set may cause inadvertent dislodgment.

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Multiple insertions with the EZ-IO® AD and PD training needle sets, drivers and

mannequins will properly prepare you for your first IO placement. Keep in mind

that you need to:

1. Place the needle set tip on the insertion site at a 90 degree angle to the tibia.

2. Lightly hold the driver in your dominant hand.

3. Allow the driver to do the work!

4. DO NOT PUSH – instead – Gently Guide!

5. Carefully feel for the “pop” or “give” indicating penetration into the

medullary space! STOP - WHEN YOU FEEL THE “POP”

*Don’t panic when you “feel the pop”! You have not penetrated the opposite

cortex – simply release your finger from the trigger and allow the rotation of the

needle set to slow while the needle tip advances another mm.

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Remove the stylet from the catheter by grasping the hub and then rotating

(unscrewing) the coupling end of the stylet counter clockwise. Once the stylet has

been released - remove it from the catheter by continuing to grasp the hub and

then gently pulling the stylet out. Be cautious with the sharp stylet.

At this point you may note blood slowly filling the catheter hub. This will serve as

additional confirmation of placement.

The stylet tip may also be checked for the presence of blood or marrow by wiping

the tip on a 4x4. This may additionally aid in confirmation of EZ-IO® PD

placement.

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Attach the EZ-Connect® extension set to the standard Luer lock & confirm placement of the

catheter. This can be accomplished by identifying several important findings:

The catheter is firmly seated and does not move.

You note blood at the catheter hub.

You are able to aspirate blood or marrow from the catheter (We recommend aspiration of

only a small amount of blood due to its extremely viscous nature).

Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or

around the tissue. Flow rates may be slow or non existent prior to the 5 ml syringe flush.

You may have checked the stylet tip for blood prior to placing it in the stylet shuttle or bio

hazard container.

Other indicators of proper placement include:

Noticing the effects of administered drugs


Four Important points to consider once the EZ-IO® PD has been established:

Routinely reconfirm that the EZ-IO® PD catheter is secure and in position.

Maintain appropriate protection at the insertion site guarding against accidental

bumping or dislodgement.

Frequently monitor the EZ-IO® PD, the fluid and the extremity.

Remove the EZ-IO® PD within 24 hours.

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Do not connect a syringe directly the EZ-IO® PD during treatment. Use of the

EZ-Connect® will help to avoid complications.

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As a general rule, consider IO after 3 attempts have been made for a peripheral

IV or when the patient’s injuries or anatomy makes IV insertion nearly

impossible (for example, patients with burns). Placing an IV in the external

jugular vein is also an option along with IO insertion.

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The EZ-IO® catheter should be removed within 24 hours!

Removal of the EZ-IO® catheter is simple. You may either grasp the hub directly or

attach a sterile syringe. (The syringe will serve as a larger handle for the catheter hub

and is preferred) Support the patient’s extremity while rotating the catheter clockwise

and gently pulling. (Recall that the exterior portion of the catheter is smooth and not

threaded). Rotating the hub during removal reduces catheter to bone friction and will

allow for an easier removal process. Be careful with the sharp catheter once

removed from the patient! Once the catheter has been removed immediately place it

in an FDA approved bio hazard sharps container. We recommend that you place a

portable sharps container near the patient for this procedure

Removal of the extension or fluid administration set, without proper protection

of the EZ-IO® hub (in the form of a sterile cap, port or extension set), could

cause bleeding or infection.

•Maintaining a 90 degree angle while rotating the catheter will insure proper

removal without complications.

* Be certain that you DO NOT ROCK the catheter while removing. Rocking or bending the catheter with a syringe may cause the catheter to

separate from the hub!

If hub-catheter separation occurs use an appropriate hemostat to grasp and

gently remove the catheter in the same manner as suggested above (rotating

while gently pulling).

ez-io ad access tibial start up training · this vidacare ez-io® ad proximal tibial access...

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