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

Intraosseous (IO) Access

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

21 Apr 2023

© Health Workforce Australia

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”

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

IO Site

• Proximal Humerus

• Sternal

• Proximal Tibia

• Distal Tibia

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

Proximal Tibial Anatomy

Many small veins lead from the medullary space to the central circulation

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

Historic complications for most IO devices

• Extravasation

• Compartment syndrome

• Dislodgement

• Fracture

• Failure (Device or user in origin)

• Pain

• Infection (Osteomyelitis/Subcutaneous abscess)

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

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

• 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?

PatellaPatella

Tibial TuberosityTibial Tuberosity

Insertion siteInsertion siteInsertion siteInsertion site

Identify Landmarks

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.

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.

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

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

Confirm and Clean Insertion SiteUse 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

EZ-IO Access

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

User induced recoil may lead to needle set dislodgement or extravasation

STOP WHEN YOU FEEL THE POP

Recoil!

Recoil!

Caution!

Caution!

Allow driver to do the work!DO NOT EXCESSIVE FORCEGently GUIDE needle set into position

Important needle set insertion tip

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

Syringe flush the catheter with 10 – 20 ml of a sterile solution

Syringe flush catheter

No Flush = No Flow

Avoid rocking the EZ-IO catheter during usage

EZ-Connect supplied with the needle set may provide additional stability

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

Bone Injection Gun (BIG)

• Choose correct device• Red = paediatric• Blue = Adult

• Adult • Set site for use on

device

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

Positioning

With one hand holding firmly, Position the BIGAt a 90 degree angel to the surface of the skin.

*use aseptic technique throughout

Removal of Safety Latch

With one hand holding theBIG 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.

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

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

Stylet trocar

Gently pull the stylet free holding the cannula in place

Remove the stylet trocar

Only Cannula remains in the bone.

Fixation

The safety latch provides additional Stability

May be completed prior to removing stylet

Aspiration

Venous blood can be aspirated into a syringe for laboratory sampling

Note:Lack of blood returndoes not mean the IO is improperly placed

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

Administration

Fluids and drugs may nowbe administered

A pressure infusion cuff may be required

Optional :Connect a stopcock to the cannula and then use a standard I.V set

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

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

EZ-IO Removal

Maintain a 90 degree angle

Maintain 90 degree angle, Rotate clockwise and gently Pull

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

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

Post Removal

Any questions?

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

Advanced Life Support Course Slide set

All rights reserved©Australian Resuscitation Council and Resuscitation Council (UK) 2010; updated 2013