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Presentation Menu Access Site Needle Flush Comfort Monitor Explore. Discover. Examine Vidacare Workshop Programmes www.vidacare.com EZ-IO Clinical Principles Clinical principles to successful IO access using EZ-IO M-XXXX Rev A menu TM TM Assess What to consider When to use EZ-IO Rule out contra indications Other considerations M-XXXX Rev A 2011 menu Access | When to use IO When to use IO When you need to give medications or fluids immediately Trauma Paediatric and Adult Shock Shock Neurological Respiratory Systemic Cardiac arrest Status epilepticus Type I and Type II Haemophiliac crisis Arrhythmia Stroke Respiratory arrest Sickle Cell crisis Myocardial infarction Coma Status asthmaticus Dehydration Congestive heart failure Head Injury Burns Drug overdose Rapid sequence intubation Chest pain End stage renal disease Dialysis menu M-XXXX Rev A 2011 Post partum haemorrhage DKA (diabetic) Access | When to use IO When to use IO When IV access is difficult or impossible Pre & Post Surgery Anaesthesia Any Peripheral IV Drug IV Fluid Therapy Obesity Young & Old 72 Hour Placement M-XXXX Rev A 2011 menu Access | Rule out contra-indications Rule out contra-indications Prosthesis Trauma to bone No Anatomical Landmarks Local Infection Recent IO in same bone (48 hrs) M-XXXX Rev A 2011 menu Access | Other considerations Other considerations prior to IO Patient needs Patient status Accessibility Post Insertion Volume replacement Pain receptiveness Position of limbs Age Accessibility to IO site Ability to monitor IO site Physique Ability to stabilise IO site Ability to maintain patient safety Trauma to limbs M-XXXX Rev A 2011 menu TM Site 8 Sites Proximal Humerus Preferred site for adults Optimal site for high flow and quick drug uptake Awake, responsive patients Less painful Distal Femur Under 6 years Proximal Tibia Site selection Unresponsive Unfamiliarity with other sites Unable to landmark Dependent upon: No previous IO in 48 hours Absence of contraindications Accessibility Larger patient Unable to access other sites Ability to secure & monitor menu M-XXXX Rev A 2011 Distal Tibia Site | Proximal humerus Proximal humerus Proximal Humerus insertion site Clavicle Greater Tuberosity Surgical Neck Humerus M-XXXX Rev A 2011 menu Site | Proximal humerus Alternately Rotate arm inwards Hand on Umbilicus M-XXXX Rev A 2011 menu Site | Proximal humerus Locate Insertion Point Locate Surgical Neck Locate Proximal Humerus Press hard moving upwards M-XXXX Rev A 2011 menu Site | Proximal humerus Angle of needle insertion Slight Downward Angle 45O from the anterior plane 45O Anterior Plane Indentify insertion point Additional Guidance menu M-XXXX Rev A 2011 45mm needle recommend for adults Advance 1 to 2cm after ‘pop’ Use EZ-IO Stabilizer Site | Proximal tibia Proximal tibia Muscle Femur Knee Cap Tibial Tuberosity Ligament (bony thickness below knee cap) Tibia menu M-XXXX Rev A 2011 R Site | Proximal tibia Proximal tibia Patients above 40 kg Actual insertion sites located Anterior (front) view (Fingers on tibial tuberosities) M-XXXX Rev A 2011 menu Site | Proximal Tibial Proximal tibia Patients up to 39kg Palpate Tibial Tuberosity M-XXXX Rev A 2011 menu Site | Proximal Tibial Proximal tibia Patients up to 39kg If Tibial Tuberosity cannot be palpated M-XXXX Rev A 2011 menu Site | Distal femur Distal femur Slightly off centre to avoid tendon Best for children under 6 years Note: May need longer needle – assess skin depth menu M-XXXX Rev A 2011 Midline of bone Site | Distal tibia Distal tibia Midline of the bone M-XXXX Rev A 2011 menu TM Needle | Needle sizes 3 Needles 15 mm 3-39 KG 25 mm > 40 KG 45 mm > 40 KG M-XXXX Rev A 2011 menu Needle | Needle features Black Mark 5mm M-XXXX Rev A 2011 menu Needle | Selection To choose correct needle, assess skin depth Depress skin tissue with thumb to gauge depth M-XXXX Rev A 2011 menu Needle | Selection Pre Drive 5mm Black Mark Check Visible blood flash or aspirate No need to see mark post drive 25mm Needle Set 45mm Needle Set NO YES Too small, mark not visible Mark visible Needle not touching the cortex Needle will then go through the cortex M-XXXX Rev A 2011 menu Needle | Selection Thin Moderate Thick Humerus tissue over bone site tissue over bone site tissue over bone site bone site (Adults) 15 25 45 45 mm mm mm mm Insert the needle tip through skin until bone felt Can the black 5mm mark be seen? No Select next size up Yes Insert needle M-XXXX Rev A 2011 menu Needle | Check After insertion, check… Firmly seated needle Flash of blood No leaking around site No sign of extravasation Secure using EZ Stabilizer Use EZ Connector EZ-IO wrist band placed M-XXXX Rev A 2011 menu TM Flush Flush for flow IO space filled with thick fibrin mesh Pressure flush to open mesh Flush can be painful Pressurised flow needed M-XXXX Rev A 2011 menu Flush | Flow Maintain flow approx 1/3 arterial pressure Medullary space pressure can stop flow Infusions should be pressurised for optimal flow M-XXXX Rev A 2011 menu Flush Yes Analgesia Recommended Alert Patient ? No Consider need for analgesia later Flush with 0.9% Saline Administer analgesia prior to flush 10ml Adults Up to 5ml Children May need to be repeated M-XXXX Rev A 2011 menu TM Comfort Many procedures hurt... IM Injections | IV Cannula | Central Line Insertion | Sub-cut. Infusions | IO M-XXXX Rev A 2011 menu Comfort Pain sensors Pressure sensors Two causes of pain Insertion specific short duration Flush, Aspiration & Infusion menu M-XXXX Rev A 2011 general diffuse protracted Comfort Proximal humerus less painful Proximal Humerus Philbeck et al 2010 Distal Femur Proximal Tibia Distal Tibia M-XXXX Rev A 2011 menu Comfort Administration Consider Local protocols Medications intended to remain in the medullary space, such as a local anaesthetic, must be administered very slowly until the desired anaesthetic effect is achieved Lignocaine for patients responsive to pain. (1) Physician must decide the appropriate analgesia & dose. Give prior to IO flush. (1) Follow institutional protocols & policies Repeat doses may be needed for continued analgesia. (1) menu M-XXXX Rev A 2011 (1) Source: Dr Richard Hixson 2011 Please refer to reference sheet or visit www.pawz.net Comfort | Suggested analgesia administration Responsive to pain? Flush the IO needle with up to 10 ml sodium chloride 0.9% over 5 seconds Yes Exclude contra-indications to cardiac lidocaine Inject or infuse fluids and medication under pressure as required (2) Monitor patient clinically. Consider additional monitoring as indicated If discomfort reoccurs Administer initial (higher) dose of IO lidocaine over 1 to 2 minutes (1) Consider repeating the subsequent (lower) dose of IO lidocaine at a maximum frequency of once every 45 min Flush the IO needle with up to 10 ml sodium chloride 0.9% over 5 seconds (2) Administer subsequent (lower) dose of IO lidocaine over 30 seconds (1) Inject or infuse fluids and medication under pressure as required (2) Source: Dr Richard Hixson 2011 Please refer to reference sheet or visit www.pawz.net Disclaimer: Whilst every care has been taken to ensure that doses and recommendations are correct, the responsibility for final check must rest with the prescriber.© Dr Richard Hixson 2011, all rights reserved. TM Monitor EZ-IO - What to monitor and record Suggest adapting local policies for the management of IV cannula and CVC lines Site Needle Patient Flow No leaking Is secure Limb perfusion Is intact No pain from IO infusion Pressurised Infusion (adults) Signs of: EZ-IO Band is insitu Expected flow achieved Extravasation EZ Stabilizer is secure Compartment Syndrome Connections are secure Pharma effects Infection M-XXXX Rev A 2011 menu Summary What we have covered TM