The 5 Rights of Intraosseous Vascular Access

1. The 5 Rights of Intraosseous Vascular Access T-430 Rev, G

2. The 5 Rights of the EZ-IO • The Right Site • The Right Needle • The Right Pain Management • The Right Flush • The Right Amount of Pressure T-430 Rev, G

3. Who Needs an IO? • For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.

4. “I Can ALWAYS Get a Line…” • Excessive Tissue • Burns • Dehydration • Renal patients • Sepsis • Diabetics • Hypertensive Crises • “C” before “A”? • Major Trauma • IVDA Is it adequate vascular access? T-430 Rev, G

5. Contraindications • Fracture to the targeted bone • Previous orthopedic procedure to targeted limb • Prosthetic limb or joint • IO within the past 24 - 48 hours in the targeted bone • Infection at the insertion site • Inability to locate landmarks or excessive tissue T-621, Rev G

6. Anatomyof Intraosseous Access Thousands of small veins lead from the medullary space to the central circulation. T-430 Rev, G

7. Real-time Flow Rate Studies T-430 Rev, G

8. Site selection is dependent upon: Absence of contraindications Accessibility of the site Ability to monitor and secure the site The Right Site T-430 Rev, G

9. Selection based on: Needle Length (15 mm, 25 mm, and 45 mm) Soft tissue depth estimated by using your finger Visualization of a black line after penetration of the skin The 45 mm needle should be considered for all proximal humerus insertions – patients >40 kg Special situations Excessive soft tissue Excessive muscle tissue Edema The Right Needle T-430 Rev, G

10. Three Needle Sets 5 mm mark or “black line” 15 gauge 15 mm/15g 25 mm/15g 45 mm/15g Length and color are the only differences between Needle Sets T-430 Rev, G

11. Egg Insertion Video T-430 Rev, G

12. What Can be Infused? • Any medication that can be safely given through a peripheral vein can be given safely through an IO • IO and IV doses are the same T-430, Rev G

13. Laboratory Analysis • Attach syringe directly to the secured and stabilized hub • Draw 2ml for waste or blood cultures • Aspirate IO blood for standardized labs • May use heparinized syringe • Label tubes as IO blood T-430, Rev G

14. IO Lab Analysis StudyCompared lab results between IO and IV in human volunteers • The following lab values produced a statistically significant correlation between IO and venous blood: - Chloride - Calcium - BUN - Creatinine - Hematocrit - Hemoglobin - Glucose • WBC was higher • Blood gases – IO values were between arterial and venous T-430, Rev G

15. Confirm and Clean Insertion Site T-430 Rev, F

16. Pediatric EZ-IO Insertion Pediatric insertion requires a gentle grip and a soft touch One size does not fit all - Consider tissue depth in needle selection Be cautious of driver recoil - Release the trigger when you feel the lack of resistance The EZ-Stabilizer is highly recommended on newborns and infants Recoil! Caution! T-430 Rev, G

17. T-453 Rev A

18. Identifying the pediatric EZ-IO insertion site If the Tibial Tuberosity CANNOTbe palpated the insertion site is two finger widths below the Patella (and then) medial along the flat aspect of the Tibia The Tibial Tuberosity can be difficult or impossible to palpate on younger patients

19. T-453 Rev A

20. Identifying the pediatric EZ-IO insertion site If the Tibial Tuberosity CAN be palpated the insertion site is one finger width below the Tuberosity (and then) medial along the flat aspect of the Tibia As patients mature the Tibial Tuberosity becomes easier to identify

21. Prepare Equipment Inspect needle packaging for damage and sterility Open EZ-Connect and prime w/saline (or consider 2% lidocaine for patients responsive to pain) Leave syringe attached to EZ-Connect Open package and attach Driver to Needle Set (leave cap on needle until ready to insert) T-430 Rev, G

22. Remove Needle Set Safety Cap T-430 Rev, G

23. Stabilize Extremity Guard against unexpected patient movement. T-430 Rev, G

24. Insert Needle Set at a 90o angle to the bone – insert through the skin until you touch bone T-430 Rev, G

25. Note that a black line is NOT visible above the skin Appropriate Needle Set Selection Matters! Note that the 5 mm mark is NOT visible above the skin Black line Needle Sizes  Consider tissue depth PRIOR to bone insertion T-430 Rev, G

26. Do not Apply Excessive Force Apply the minimal amount of pressure required to keep the driver advancing straight into thebone. T-430 Rev, G

27. Remove Driver from Needle Set Stabilize the Needle Set while disconnecting Driver. T-430 Rev, G

28. Stabilize Needle Set and rotate the stylet counter-clockwise Remove stylet and dispose of in approved bio-hazard sharps container Apply EZ-Stabilizer before attaching the primed EZ-Connect Removal of the Stylet T-430 Rev, G

29. Put Stylets Where They Belong . . . in approved biohazard containers. Portable sharps protector T-430 Rev, G

30. Note one or more of the following: Firmly seated catheter Flash of blood in the catheter hub or blood on aspiration * Pressurized fluids flow without difficulty Pharmacologic effects * may or may not be able to aspirate blood Confirm Catheter Placement Monitor for signs of extravasation. T-430 Rev, G

31. Intraosseous Usage and Pain Insertion pain is specific, and of short duration Infusion pain is general, diffuse and protracted T-430 Rev, G

32. Sometimes it Hurts… • Foley Catheter • Nasogastric Tube • Multiple IV Sticks • Central Lines • Spinal Taps • IM Injections • Adhesive Removal • Dressing Changes • Wound Debridement • Clysis T-430 Rev, G

33. Pain Management • Consider IO 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) for patients responsive to pain prior to flush. Follow institutional protocols/policies. • Medications intended to remain in the medullary space, such as a local anesthetic, must be administered very slowly until the desired anesthetic effect is achieved. *Physician must determine appropriate dosage range T-430 Rev, G

34. 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 may be required to achieve maximum flow rate The Right Flush T-430 Rev, G

35. Syringe FLUSH Catheter Prime and use extension set Flush IO catheter with 10ml of saline Reminder: For patient’s responsive to pain consider 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) via the IO PRIOR to syringe flush Some patients may require multiple syringe flushes No Flush = No Flow T-430 Rev, G

36. The pressure in the medullary space is approximately 1/3 of the patients arterial pressure Pressurizing fluids for infusion is required to obtain maximum flow rates For aggressive fluid resuscitation a rapid infuser may increase flow rates The Right Amount of Pressure T-430 Rev, G

37. Infuse Fluids with Pressure Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered. T-430 Rev, G

38. Maintain axial alignment – DO NOT rock the syringe EZ-IO Removal Rotate syringe clockwise while pulling straight back Back the EZ-IO catheter out of patient while stabilizing the extremity. T-430 Rev, G

39. The 5 Rights of the EZ-IO • The Right Site • The Right Needle • The Right Pain Management • The Right Flush • The Right Amount of Pressure T-430 Rev, G

40. Cleaning & Disinfecting Wipe clean with moistened cloth Spray with anti-microbial solution Momentarily depress trigger several times during cleaning Clean around drive shaft with cotton applicator – check to ensure nothing has attached to the magnetic tip Wipe dry Inspect driver and return to case or replace trigger guard DO NOT SUBMERGE DRIVER AT ANY TIME T-430 Rev, G

41. Clinical Support • Wrist band • 24 hour Emergency Line • 1-800-680-4911 • www.vidacare.com • Web Feedback form T-430 Rev, G

42. Questions? Please review “Directions For Use” before using the EZ-IO. T-430 Rev, G