The 5 Rights of Intraosseous Vascular Access

T-430 Rev, FLinda Arapian RN MSN

MCFRS

The 5 Rights of the EZ-IO

1. The Right Site

2. The Right Needle

3. The Right Pain Management

4. The Right Flush

5. The Right Amount of PressureT-430 Rev, G

Who Needs an IO?

• For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.

T-430 Rev, G

Maryland Medical Protocols July 2011

• INDICATIONS FOR IO – Cardiac arrest, OR– Profound hypovolemia, OR– No available vascular access, or following two unsuccessful

peripheral IV attempts for patients with..life-threateningillness or injury requiring immediate pharmacological orvolume intervention, OR

- In pediatric patients in cardiac arrest, go directly to IO if no peripheral sites are obvious and without having to attempt

peripheral access

Contraindications

• Fracture to the targeted bone

• Previous orthopedic procedure to targeted limb– Prosthetic limb or joint

• IO within the past 48 hours in the targeted bone

• Infection at the insertion site

• Inability to locate landmarks or excessive tissue

T 430 Rev G

Maryland Medical Protocols July 2011Contraindications

ADDITIONAL Contraindications for IO placement:

• Conscious patient with stable vital signs

• Peripheral access readily available

Thousands of small veins lead from the medullary space to the central circulation.

T-430 Rev, G

Anatomy of Intraosseous Access

The Right Flush

• 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

T-430 Rev, F

The Right Site

Site selection is dependent upon:

• Absence of contraindications

• Accessibility of the site

• Ability to monitor and secure the site

NOTE: Sternum is NOT a site

T-430 Rev, G

Maryland Medical Protocols July 2011Acceptable Sites

Manual placement• Under 6yo – proximal tibia site• Over 6 yo – distal tibia site

Mechanical Placement• 3-39 Kg - proximal tibia• > 40 Kg - adult needle in proximal tibia• > 40 Kg - adult needle in distal tibia (needle length)• > 40 Kg - use proximal humerus if lower extremity

notavailable

- proximal humerus not approved < 40 Kg

Confirm and Clean Insertion Site

T-430 Rev, G

Length and color are the only differences between Needle Sets

25 mm/15g 45 mm/15g

5 mm mark or

“black line”

15 mm/15g

T-430 Rev, G

15 gauge

Three Needle Sets

The Right NeedleSelection 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

T-430 Rev, G

Note that the 5 mm

mark is NOT visible

above the skin

T-430 Rev, G

Appropriate Needle Set

Selection Matters!

Note that a black line is NOT

visible above the skin

Needle Sizes

 Consider tissue depth PRIOR to bone insertion

Black line

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

Remove Needle Set Safety Cap

T-430 Rev, G

Stabilize Extremity

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

Insert Needle Set at a 90o angle to the bone – insert through the skin until you touch bone

T-430 Rev, G

Apply the minimal amount of pressure required to keep the driver advancing straight into the bone.

T-430 Rev, G

Do not Apply Excessive Force

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

Cau

tion

!

Cau

tion

!

Recoi

l!

Recoi

l!

T-430 Rev, G

Remove Driver from Needle Set

T-430 Rev, G

Stabilize the Needle Set while disconnecting Driver.

• 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

T-430 Rev, G

Removal of the Stylet

Portable sharps protector

Put Stylets Where They Belong . . .

in approved biohazard containers.T-430 Rev, G

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

Monitor for signs of extravasation.

Confirm Catheter Placement

T-430 Rev, G

No Flush = No Flow

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

T-430 Rev, G

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

Intraosseous Usage and Pain

Insertion pain is specific,

and of short duration

Infusion pain is general,

diffuse and protracted T-430 Rev, G

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 rangeT-430 Rev, G

Maryland Medical Protocols July 2011Pain Management

Pain due to IO infusion:

Adults administer 20-40 mg of 2% cardiac lidocaine (1-2 mL 2% Lidocaine) IO

Ped > 40Kg administer 20-40mg of 2% cardiac lidocaine (1-2 mL 2% Lidocaine) IO

Peds < 40Kg Medical consultation is required

Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered.T-430 Rev, F

• 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

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

Infuse Fluids with Pressure

Clinical Support

• Wrist band

• 24 hour Emergency Line • 1-800-680-4911

• www.vidacare.com

• Web Feedback form

T-430 Rev, G

EZ-IO Removal

Back the EZ-IO catheter out of patient while stabilizing the extremity.

Maintain axial alignment – DO

NOT rock the syringe

Rotate syringe clockwise while

pulling straight back

T-430 Rev, G

DO NOT SUBMERGE DRIVER AT ANY TIME

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

T-430 Rev, G

VIDACARE Regional Clinical Contact:

T-430 Rev, F

Please review “Directions For Use” before using the EZ-IO.

 

Karen Hust RN MSN CEN

Clinical Manager - Mid-Atlantic Territory

(NJ, PA, DE, Washington DC, VA, WV, NC)

912-308-1839

Immediate Vascular Access…

                             When You Need It Most

www.vidacare.com      

The 5 Rights of the EZ-IO Review

1. The Right Site

2. The Right Needle

3. The Right Pain Management

4. The Right Flush

5. The Right Amount of PressureT-430 Rev, G

Questions?

T-430 Rev, G

Please review “Directions For Use” before using the EZ-IO.

The Right Amount of Pressure

• 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

T-430 Rev, G

“I Can ALWAYS Get a Line…”

• Excessive Tissue

• Burns

• Dehydration

• Renal patients

• Sepsis

• Diabetics

• Hypertensive Crises

• “C” before “A”?

• Major Trauma

• IVDA

T-430 Rev, G

Is it adequate vascular access?