intraosseous needle insertion kalpesh patel, md dept. of pediatric emergency medicine november 22,...
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Intraosseous Needle Insertion
Kalpesh Patel, MD
Dept. of Pediatric Emergency Medicine
November 22, 2006
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Objectives
Understand the history of intraosseous needles (IO) Understand the indications, risks, and benefits of IO
needle insertion Learn to perform:
• IO needle insertion at various locations using the manual insertion method
• IO needle insertion using new techniques
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History
Earliest reference to IO use was in 1922 First theraputic use in humans was reported in 1934 Popularized in the 1940’s for rapid access Used widely until 1950’s when the plastic catheter
was devised Reemerged in mid 80’s for resuscitation where IV
access was difficult Since then, pediatric use has become more
accepted Now used as the standard of care for emergency
access in both pediatrics and adults
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Physiology
The marrow cavity is in continuity with the venous circulation and functions as a non-collapsable venous plexus
Sinusoids serve as transport to the central venous channel exiting as nutrient and emissary veins
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Physiology
The onset of action and drug levels during CPR using the IO route are similar to those given IV • Used to infuse fluids,
blood products, and drugs
• Can take mixed venous blood samples for labs such as crossmatch, bedside tests, etc.
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Indications
When vascular access is needed in life-threatening situations
When attempts at standard venous access fail (three attempts or 90 seconds) or in cases where it is likely to fail and speed is of the essence.
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Contraindications
Femoral fracture on the ipsilateral side Do not use fractured bones Do not use bones with osteomyelitis Osteogenesis Imperfecta Osteopetrosis
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Types of IO Needles
Cook IO Needle
Jamshidi IO Needle
Illinois Sternal Iliac NeedleSur-Fast IO Screw Tip
Needle
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Equipment Required
Antiseptic prep solution Local Anesthetic (optional in the moribund patient) IO Needles
• 18-20 gauge spinal needle can be used as an alternative
• In a pinch, any needle can be used, but may get clogged with cortical bone without stylet or trochar
Syringe Flush solution Gauze pads and tape
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Locations of Insertion
3 most common locations:• Proximal Tibia
Medial side, 1-2 cm below and avoiding the tibial tuberosity
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Locations of Insertion
Distal Femur• Femur is triangular shaped.
Insert needle 1-2 cm proximal to the superior border of patella and medial or lateral to anterior ridge
Distal Tibia• 1-2 cm proximal to the
medial malleolus in the center of the bone
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Locations of Insertion
In older children and adults:• Iliac crests, preferably
Anterior Superior Iliac Spine
• Sternum
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Technique for Manual Insertion
Prep the site Inject 1-3 ml of lidocaine into the skin and down to
the periosteum (optional when time does not permit this)
Grasp needle in dominant hand and place it on the site with the needle pointing away from the joint
Pinch needle with thumb and forefinger and allow the hub to rest in the palm of your hand
DO NOT PLACE YOUR OTHER HAND BENEATH THE SITE
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Technique for Manual Insertion
Use firm downward pressure and rotate the needle back and forth
Feel for a sudden decrease in resistance or a popping sound and advance the needle a few millimeters
Remove the trochar or stylet and aspirate marrow
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Technique for Manual Insertion
Infuse fluid to determine ease of flow and no extravasation in to soft tissues around the insertion site
Secure the needle with goal post taping to allow visualization of the site
If the needle fails, then insert into a new bone because fluid will leak from the failed site
IO Insertion
http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=1528&id=1347
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Complications
Through and through penetration• Extravasation of fluids or medications into subcutaneous
tissue Compartment syndrome
Subcutaneous abscess/skin necrosis Osteomyelitis
• When an aseptic technique is used, the incidence of osteomyelitis is less than 1%
Bacteremia Epiphyseal injury and fracture (especially in neonates) Fat Embolus Bent needle Complications are reported to occur in <1% of cases
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New Methods
F.A.S.T -1 system Bone Injection Gun (BIG) EZ-IO Drill
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F.A.S.T. -1 Sternal Intraosseous Device
First Access for Shock and Trauma
Created for insertion into manubrium of adult sternum
May be used in older children
http://www.pyng.com/movies/iousemovie.html
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Bone Injection Gun
Spring loaded catheter injected into place at a preset depth
Comes in Adult and Pediatric sizes
Establishes access within 1 minute
BIG, The Movie
http://www.ps-med.com/big/description_big01.html
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EZ-IO
A battery powered electric drill which places the needle quickly into place
EZ-IO Insertion
http://www.vidacare.com/Products/index_4_29.html
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Aftercare
IO’s are emergency lines and every effort should be made to place an intravenous line after initial resuscitation
IO’s should ideally be removed within 6-12 hours All IO’s will eventually start to leak IO’s can stay in for up to 48-72 hours, but after 24
hours the risk of osteomyelitis increases dramatically
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Summary
IO’s are essentially equivalent to IV access Should be used for emergency access Many types of needles exist, but Jamshidi style is
preferred by most users Preferred insertion sites include proximal or distal
tibia, or distal femur, but in older children, iliac crests and sternum can be considered
New devices are emerging, but are not standard of care in pediatrics yet
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Questions?