Download Advanced Boo-Boo and Owie Repair

Intraosseous Needle
Insertion
Kalpesh Patel, MD
Dept. of Pediatric Emergency
Medicine
November 22, 2006
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
2
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
Jamshidi IO Needle
Cook IO Needle
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Illinois Sternal Iliac Needle
Sur-Fast IO Screw Tip
Needle
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
14
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
15
IO Insertion
http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=1528&id=1347
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
17
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
20
BIG, The Movie
http://www.ps-med.com/big/description_big01.html
EZ-IO
 A battery powered
electric drill which
places the needle
quickly into place
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EZ-IO Insertion
http://www.vidacare.com/Products/index_4_29.html
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?
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