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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
May
© Health Workforce
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
Intraosseous access: is it painful?
• 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
Identify Landmarks
Patella
Tibial Tuberosity
Insertion site
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 Site
Use 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
40 kg and greater usage
Position the EZ-IO Driver
at a 90 degree angle to the
bone
Remember
“EZ does it”
Lightly holding the EZ-IO driver
will improve usage
Don’t force the needle set into position - “allow the driver to do the work”
Important needle set insertion tip
Allow driver to do the work!
DO NOT EXCESSIVE FORCE
Gently GUIDE needle set into position
STOP WHEN YOU
FEEL THE POP
User induced recoil may lead to needle set dislodgement or extravasation
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 catheter
No Flush = No Flow
Syringe flush the catheter with 10 – 20 ml of a sterile solution
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
Units 22-24
60-66 Richmond Road,
Keswick 5035, South Australia
Telephone: 8351 1455
Facsimile:8293 7377
Email: [email protected]
www.implox.com
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 BIG
At a 90 degree angel to
the surface of the skin.
*use aseptic technique
throughout
Removal of Safety Latch
With one hand holding the
BIG 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 return
does 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 now
be 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
Maintain axial alignment –
DO NOT rock the syringe
Rotate syringe clockwise
while pulling straight back
Back the EZ-IO catheter out of patient while stabilising the extremity
T-430 Rev, G
Post Removal
Once catheter has been removed – cover site and monitor patient
according to local policy and guidelines
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
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©Australian Resuscitation Council and Resuscitation Council (UK) 2010; updated 2013