review of current intraosseous infusion devices. lecture outline review relevant anatomy,...

Review of Current Intraosseous Review of Current Intraosseous Infusion DevicesInfusion Devices

Review of Current Intraosseous Review of Current Intraosseous Infusion DevicesInfusion Devices

Lecture OutlineLecture OutlineLecture OutlineLecture Outline

• Review relevant anatomy, Review relevant anatomy, indications, & contraindicationsindications, & contraindications

• Present background reasons for Present background reasons for interest in expanding use of interest in expanding use of intraosseous (IO) line insertion in intraosseous (IO) line insertion in adultsadults

• Describe the insertion procedure for Describe the insertion procedure for the 4 types of currently approved IO the 4 types of currently approved IO devicesdevices

Relevant AnatomyRelevant Anatomy

Thousands of small veins lead from the bone medullary space to the general circulation

Anatomy of long bonesAnatomy of long bones

Intraosseous (IO) Pressure and Intraosseous (IO) Pressure and Flow RatesFlow Rates

Intraosseous (IO) Pressure and Intraosseous (IO) Pressure and Flow RatesFlow Rates

• With a pressure bag or IV pump, Intraosseous (IO) flow rates are similar to IV’s through a 21-gauge needle.

• Rate of infusion that can be given IO under 300 mm pressure : • 2 to 50 cc / min (average 10 cc / min)

• 120 to 3,000 cc / hour (average 600 cc / hour)

• Unit of blood in about 30 minutes

• Rate of infusion that can be given IO under 1 meter gravity :

• 1 to 15 cc / min (average 4 cc / min)

• Unit of blood in about 60 minutes

• Unit dose injections can be given in seconds (5cc in 3 sec)

• Rapid 10 cc syringe bolus dramatically increases IO flow rates

If no flush ---- there may be no flow !If no flush ---- there may be no flow !

Intrinsic IO PressureIntrinsic IO Pressure

IO Infusion of MedicationIO Infusion of Medication

• Which Drugs can be given ?

• Any medications that can be safely injected into a peripheral IV can likewise be safely injected IO

• Caution with cytotoxic drugs and hypertonic saline

• What Dose ?

• IO medication doses are the same as those for IV injection

• Flow rates (Rapid 10 cc bolus must be given first) :

• To maintain optimal flow, pressure of 300 mm Hg must be applied to the infusion bag or the pump

• Testing :

• 5 cc of blood can be aspirated from an IO device and placed into a heparin-coated syringe for standard laboratory testing

Potential IO ComplicationsPotential IO ComplicationsPotential IO ComplicationsPotential IO Complications

• Extravasation (leakage)• Dislodgement• Compartment syndrome• Fracture of the bone• Failure • Pain (more about this on next slide)• Infection

• Experience in thousands of children and reports on 4,000 adults show the infection rate to be less than 0.6 % and those infections are usually not serious (can be treated as outpatients with removal of device)

Mortality from above complications : NoneMortality from above complications : None

Pain from IO InsertionPain from IO InsertionPain from IO InsertionPain from IO Insertion

• 85 % of IO patients will be unconscious85 % of IO patients will be unconscious

• For them, pain is not an issueFor them, pain is not an issue

• For the conscious patient : pain is an issueFor the conscious patient : pain is an issue

• Pain related to insertion of needle : Pain related to insertion of needle : MinimalMinimal

• May numb the skin and periosteum with local xylocaineMay numb the skin and periosteum with local xylocaine

• Pain related to infusion of meds / fluids (visceral pressure)Pain related to infusion of meds / fluids (visceral pressure)

• Numb the vessels by injecting xylocaine 10 mg IONumb the vessels by injecting xylocaine 10 mg IO

• Psychological anxiety : “You are going to do what ?”Psychological anxiety : “You are going to do what ?”

• Talk to your patient firstTalk to your patient first

Two Kinds of Pain Two Kinds of Pain Related to IO InsertionRelated to IO Insertion

IO ContraindicationsIO ContraindicationsIO ContraindicationsIO Contraindications

• Local InfectionLocal Infection

• Major trauma to extremity : fractures in same limbMajor trauma to extremity : fractures in same limb

• ProsthesisProsthesis

• Recent (24 hours) previous IORecent (24 hours) previous IO

• Vascular compromise : diabetic leg (relative Vascular compromise : diabetic leg (relative

contraindication)contraindication)

• Absence of anatomical landmarksAbsence of anatomical landmarks

• Osteogenesis ImperfectaOsteogenesis Imperfecta

IO IndicationsIO IndicationsIO IndicationsIO Indications

• Cardiac arrestCardiac arrest• Status Status eepilepticuspilepticus• Shock / TraumaShock / Trauma• ArrhythmiaArrhythmia• DehydrationDehydration• BurnsBurns• Drug overdoseDrug overdose• DKA (diabetic)DKA (diabetic)• End stage renal diseaseEnd stage renal disease• StrokeStroke• Myocardial infarctionMyocardial infarction

IV access is often difficult or impossible in these

situations.IO is the Answer !IO is the Answer !

•ComaComa•Head InjuryHead Injury•AnaphylaxisAnaphylaxis•Congestive heart Congestive heart failurefailure•DialysisDialysis•EmphysemaEmphysema•Respiratory arrestRespiratory arrest•Hemophiliac crisisHemophiliac crisis•Sickle Cell crisisSickle Cell crisis•Pediatric shockPediatric shock•Chest painChest pain

Anatomic Sites for IO InsertionAnatomic Sites for IO InsertionAnatomic Sites for IO InsertionAnatomic Sites for IO Insertion

• Just below and medial to tibial Just below and medial to tibial tubercle (preferred site for both tubercle (preferred site for both children and adults)children and adults)

• Lower anterior femur (for children)Lower anterior femur (for children)• Alternative sites for adults :Alternative sites for adults :• Ankle medial malleolusAnkle medial malleolus• Anterior humeral headAnterior humeral head• SternumSternum• PatellaPatella

Current IO State-of-the-ArtCurrent IO State-of-the-ArtCurrent IO State-of-the-ArtCurrent IO State-of-the-Art

• Universally taught as a core skill to :Universally taught as a core skill to :• ParamedicsParamedics

• Emergency physiciansEmergency physicians

• Emergency and Pediatric NursesEmergency and Pediatric Nurses

• Used as a rescue IV access port in pediatricsUsed as a rescue IV access port in pediatrics• Current Standard of Care for childrenCurrent Standard of Care for children

• So far only used sporadically in adultsSo far only used sporadically in adults

• New groundswell of interest for adults in past yearNew groundswell of interest for adults in past year

• New ACLS, PALS, ATLS, ENPC guidelines New ACLS, PALS, ATLS, ENPC guidelines recommend adult IO for difficult vascular accessrecommend adult IO for difficult vascular access

The IO Paradigm is ChangingThe IO Paradigm is ChangingThe IO Paradigm is ChangingThe IO Paradigm is Changing

• No adult devices :No adult devices : New adult IO devices have been FDA approved.New adult IO devices have been FDA approved.

• Fear :Fear : 15 years experience in children has dispelled the fear of 15 years experience in children has dispelled the fear of

penetrating someone’s bone.penetrating someone’s bone.

• Infection :Infection : Infection has not been a problem.Infection has not been a problem.

• Pain :Pain : Pain is controllable.Pain is controllable.

• Difficult :Difficult : New devices make the procedure easier than starting an IV.New devices make the procedure easier than starting an IV.

• No Support :No Support : Strong support from military, EMS, ER, ACLS.Strong support from military, EMS, ER, ACLS.

• Now the Now the “Standard of Care”“Standard of Care” : PALS, ACLS, Military . : PALS, ACLS, Military .

““The use of IO devices is a promising The use of IO devices is a promising

technique to establish emergency technique to establish emergency

access in access in adultadult patients” patients” . .

American Heart Association : 2003

ACLS Principles & Practice

New IO MandateNew IO Mandate

Military Interest in IO’sMilitary Interest in IO’sMilitary Interest in IO’sMilitary Interest in IO’s

IV’s Are Difficult in Military IV’s Are Difficult in Military SituationsSituations

IV’s Are Difficult in Military IV’s Are Difficult in Military SituationsSituations

• Battlefield conditionsBattlefield conditions

• Darkness with use of night vision equipment Darkness with use of night vision equipment

• Hot or cold environmentsHot or cold environments

• Stressful : bullets flying overheadStressful : bullets flying overhead

• Ratio of medics to troops : 1 to 40 or higherRatio of medics to troops : 1 to 40 or higher

• Medic has to carry everything he needs in his rucksack (50 kg limit)Medic has to carry everything he needs in his rucksack (50 kg limit)

• Training & experienceTraining & experience

• Medics are generally well trainedMedics are generally well trained

• But have little opportunity for experience until actually needed But have little opportunity for experience until actually needed

• Is civilian prehospital trauma care any different ?Is civilian prehospital trauma care any different ?

• IV’s are just as difficultIV’s are just as difficult

• Many of the same factors applyMany of the same factors apply

Unnecessary DeathsUnnecessary DeathsUnnecessary DeathsUnnecessary Deaths

• Acute hemorrhage is the major cause of Battlefield MortalityAcute hemorrhage is the major cause of Battlefield Mortality

• 50 % are killed immediately50 % are killed immediately

• 50 % die within 1 hour of injury50 % die within 1 hour of injury

• Improvement in care requiresImprovement in care requires

• Control of bleedingControl of bleeding

• Rapid IV administration of blood & fluidsRapid IV administration of blood & fluids

• Most serious casualties go into shockMost serious casualties go into shock

• Veins collapse making IV access difficultVeins collapse making IV access difficult

• Average time for a medic to start an IV = 12 minutesAverage time for a medic to start an IV = 12 minutes

• Average success rate in battlefield conditions = 30 %Average success rate in battlefield conditions = 30 %

For 10 casualties it could take 2 hours to start IV’sFor 10 casualties it could take 2 hours to start IV’s

National Academy of SciencesInstitute of Medicine, 1999

F.D.A. Approved IO DevicesF.D.A. Approved IO DevicesF.D.A. Approved IO DevicesF.D.A. Approved IO Devices

• Jamshidi / Illinois Sternal / Cook (manually pushed in) needlesJamshidi / Illinois Sternal / Cook (manually pushed in) needles

• Mostly used for pediatrics

• F.A.S.T. Pyng (Bed of Nails)F.A.S.T. Pyng (Bed of Nails)

• Designed for adult sternum

• Manually inserts 10 needles at once

• B.I.G. Bone Injection Gun (Nail Gun)B.I.G. Bone Injection Gun (Nail Gun)

• Shoots a needle into adult tibia and other bones

• EZ-IO (Battery Powered Drill) by VidaCare Company

• Powers a hollow drill (Catheter) into the medullary space

Manually Inserted IO NeedlesManually Inserted IO Needles

Manually inserted hand held infusion needles have been

available for years.

Mostly used for infants because

their bones are soft.

PYNG (F.A.S.T.) IO DevicePYNG (F.A.S.T.) IO DevicePYNG (F.A.S.T.) IO DevicePYNG (F.A.S.T.) IO Device

F.A.S.T. Insertion ProcedureF.A.S.T. Insertion ProcedureF.A.S.T. Insertion ProcedureF.A.S.T. Insertion Procedure

Do not attempt to use the F.A.S.T. 1 Do not attempt to use the F.A.S.T. 1 system unless you have been system unless you have been

formally trained, evaluated, and formally trained, evaluated, and authorized to perform this procedure !authorized to perform this procedure !


1.1. Undo or cut shirt to Undo or cut shirt to expose sternum.expose sternum.

2. Prepare the area of the manubrium with the iodine and alcohol swabs included in the package : wipe the area 1” below the sternal notch.


4.4. Place index finger in Place index finger in patient’s sternal notch ; patient’s sternal notch ; the locating finger must the locating finger must be perpendicular to the be perpendicular to the manubrium.manubrium.

5.5. Align Patch notch with Align Patch notch with patient’s sternal notch.patient’s sternal notch.

3. Remove top half of backing

labeled 1.


7.7. Reaching under the Reaching under the Patch, remove backing Patch, remove backing labeled 2 and press labeled 2 and press Patch to skin.Patch to skin.

6. Secure first half of the patch by pressing firmly downward, engaging the adhesive.


8.8. Verify location : check that Verify location : check that the locating notch the locating notch matches the sternal notch matches the sternal notch and that the Target Zone is and that the Target Zone is over the manubrium. over the manubrium.

9.9. This is critical for safe and This is critical for safe and effective placement of the effective placement of the device.device.


10.10. Remove Sharps Cap from the Remove Sharps Cap from the introducer ; the clear plastic introducer ; the clear plastic Sharp Cap can be removed by Sharp Cap can be removed by slightly twisting and pulling slightly twisting and pulling away.away.

11.11. Place the bone probe cluster in Place the bone probe cluster in the target zone with its long axis the target zone with its long axis PERPENDICULAR (90 DEGREES) PERPENDICULAR (90 DEGREES) TO THE SKIN. TO THE SKIN.

12.12. Ensure needle cluster is within Ensure needle cluster is within the target zone.the target zone.


• The force must be applied The force must be applied in line with the long axis of in line with the long axis of the Introducer ; the forearm the Introducer ; the forearm and elbow must be in line and elbow must be in line with Introducer’s axis.with Introducer’s axis.

• After release pull straight After release pull straight back to remove the back to remove the Introducer. Introducer.

13. Press the Introducer into the target zone with firm and increasing force, until a distinct release of the Introducer handle is heard and felt.

14

15


Attach the right-angle Attach the right-angle female connector to the female connector to the infusion tube. infusion tube.

• Attach syringe to straight female connector and withdraw marrow into the Infusion Tube to verify successful placement.

• Remove and discard syringe.

16.

17

18


Place the protector Place the protector dome over the patch and dome over the patch and press down firmly to press down firmly to engage the velcro engage the velcro fastening.fastening.

19.

F.A.S.T. Removal ProcedureF.A.S.T. Removal ProcedureF.A.S.T. Removal ProcedureF.A.S.T. Removal Procedure

• Remove the Protector Dome from the Target Remove the Protector Dome from the Target

Patch.Patch.

• Disconnect the Infusion Tube from the right Disconnect the Infusion Tube from the right

angle female connector on the Patch.angle female connector on the Patch.

Do not pull on the infusion tube to Do not pull on the infusion tube to remove it !remove it !

20

21

F.A.S.T. Removal Procedure F.A.S.T. Removal Procedure (Continued)(Continued)

F.A.S.T. Removal Procedure F.A.S.T. Removal Procedure (Continued)(Continued)

• Insert the Remover into the Infusion Tube : keep the Infusion Tube straight out (90 degrees) from the patient.

• Advance the remover till you Advance the remover till you hear or feel it enter the threads hear or feel it enter the threads in the proximal tip of the in the proximal tip of the infusion tube.infusion tube.

• Turn the remover clockwise Turn the remover clockwise until it stops.until it stops.

• Pull straight out on the remover Pull straight out on the remover to remove the infusion tube.to remove the infusion tube.

2

1

3

4

The The B.I.GB.I.G™ IO Device™ IO Device

Adult B.I.G : 15 GaugeFDA Approved

Pediatric B.I.G : 18 Gauge

FDA Approved

B.I.G. Technique of InsertionB.I.G. Technique of Insertion

Use a povidone iodine tincture sponge to clean the selected site for injection.

Position the front of the B.I.G™ at the selected site, holding and pushing firmly on the rear of the instrument.

B.I.G. Insertion SequenceB.I.G. Insertion SequenceB.I.G. Insertion SequenceB.I.G. Insertion Sequence

..1

2

3

4

5


Position the BIG with one hand to the site and pull out the Safety Latch with the other hand.

B.I.G. Technique of insertionB.I.G. Technique of insertion

Trigger the BIG at 90º to the surface.


Remove the BIG. Pull out the stylet (trocar).

Technique of insertionTechnique of insertion

Fix the cannula with the Safety Latch.

Connect IV Set with a stopcock and flush with 1 mg / kg for IO local anesthetics.

The “EZ-IO” Drill DeviceThe “EZ-IO” Drill DeviceThe “EZ-IO” Drill DeviceThe “EZ-IO” Drill Device

““Making difficult IV accessMaking difficult IV accessa thing of the past”a thing of the past”

Jointly owned and developed by

The University of Texas Health Science Center&

VidaCare Corporation

....

Univ. of Texas in

San Antonio

Dr. Larry Miller who developed the EZ-IO device

EZ-IO DescriptionEZ-IO DescriptionEZ-IO DescriptionEZ-IO Description

• Establishes IO access simply & automaticallyEstablishes IO access simply & automatically

• Uses a hollow drill to enter the boneUses a hollow drill to enter the bone

• Small battery powered driver implants the needleSmall battery powered driver implants the needle

• Enables immediate access for all drugs and fluidsEnables immediate access for all drugs and fluids

• Provides safe and easy IO access for adultsProvides safe and easy IO access for adults

““A kinder - gentler way”A kinder - gentler way”

Final DesignFinal Design

The EZ-IO drill

EZ-IO needle

and sheath

Use of the EZ IO drill in a pediatric patient

EZ IO needle placed in tibia

Connector tubing for the EZ IO

How Adult EZ-IO Infusion BenefitsHow Adult EZ-IO Infusion BenefitsEmergency MedicineEmergency Medicine

How Adult EZ-IO Infusion BenefitsHow Adult EZ-IO Infusion BenefitsEmergency MedicineEmergency Medicine

• Saves time Saves time

• Takes less than 10 secondsTakes less than 10 seconds

• IV’s take an average of 8 minutes IV’s take an average of 8 minutes

• One provider can treat multiple patients (Mass casualties)One provider can treat multiple patients (Mass casualties)

• Faster transport (less time on scene)Faster transport (less time on scene)

• Improves throughput time (in the emergency department)Improves throughput time (in the emergency department)

• Can be started en route (less scene time)Can be started en route (less scene time)

• Allows provider to handle other problems : i.e. airway, medsAllows provider to handle other problems : i.e. airway, meds

How Adult EZ-IO Infusion Benefits How Adult EZ-IO Infusion Benefits Emergency Medicine (cont.)Emergency Medicine (cont.)


• Easy to TeachEasy to Teach

• Short learning curveShort learning curve

• Technique can be taught in less than one hourTechnique can be taught in less than one hour

• Easy to remember (skill retention)Easy to remember (skill retention)

• High success rate builds confidenceHigh success rate builds confidence

• Huge benefit for first responders with limited critical care Huge benefit for first responders with limited critical care

exposureexposure



• Easy to UseEasy to Use

• Large target areaLarge target area

• High success rate (better than 97 %)High success rate (better than 97 %)

• High retention of skill level High retention of skill level

• Intuitive procedureIntuitive procedure

• Vastly easier than starting IV’sVastly easier than starting IV’s

• May be used by Basic EMT’sMay be used by Basic EMT’s

How the EZ-IO Device Benefits How the EZ-IO Device Benefits Emergency MedicineEmergency Medicine

How the EZ-IO Device Benefits How the EZ-IO Device Benefits Emergency MedicineEmergency Medicine

• Easy to MaintainEasy to Maintain

• Rugged : designed for the emergency environmentRugged : designed for the emergency environment

• Long shelf lifeLong shelf life

• Replaceable AA batteriesReplaceable AA batteries

• Operates at wide temperature rangeOperates at wide temperature range

• Easy to cleanEasy to clean

• Small storage space requiredSmall storage space required

• Replacement parts sent overnight (24 hour support)Replacement parts sent overnight (24 hour support)

IO SummaryIO SummaryIO SummaryIO Summary

• Venous access in shock is often difficult or impossibleVenous access in shock is often difficult or impossible

• Thousands die because of lack of IV fluids & drugs.Thousands die because of lack of IV fluids & drugs.

• IO has been used successfully for 65 yearsIO has been used successfully for 65 years

• The science behind it is solid ; its’ rationale is sound.The science behind it is solid ; its’ rationale is sound.

• Inside the bone is a huge non-collapsible veinInside the bone is a huge non-collapsible vein

• Functions well in shock states.Functions well in shock states.

• Last 15 years in kids demonstrates IO to be Safe & EffectiveLast 15 years in kids demonstrates IO to be Safe & Effective

• Serious side effects are very rare (less than 1%).Serious side effects are very rare (less than 1%).

• IO has saved many children’s lives.IO has saved many children’s lives.

• Currently IO is vastly underutilized in adults Currently IO is vastly underutilized in adults

• IO should be considered first line treatment in serious illnesses for IO should be considered first line treatment in serious illnesses for

children and adults .children and adults .

IO SummaryIO SummaryIO SummaryIO Summary

• We are witnessing a major paradigm shift in IO use for We are witnessing a major paradigm shift in IO use for

adults :adults :

• ““With adult-IO, you no longer have to worry about time With adult-IO, you no longer have to worry about time

consuming and often exasperating IV access. You can now consuming and often exasperating IV access. You can now

concentrate on the more important aspects of airway concentrate on the more important aspects of airway

management, arrhythmias, fluid resuscitation, wound management, arrhythmias, fluid resuscitation, wound

management and scene time”management and scene time” . .

Larry Miller M.D .

review of current intraosseous infusion devices. lecture outline review relevant anatomy,...

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