Intraosseous Access

UNCONTROLLED WHEN PRINTED

Indications

Cannulation of the intraosseous space using EZ-IO:

Cardiac arrest:
- First line cardiac arrest management for paediatrics
- Consideration for first line access in traumatic cardiac arrest
- Second line cardiac arrest management for adults following at least one failed intravenous (IV) access attempt.
All other circumstances:
- Where immediate medication administration is required following at least one failed intravenous (IV) access attempt when unable to administer via any other appropriate route.

Contraindications

Fracture to the targeted bone.
IO within last 48 hours in the targeted bone.
Inability to locate landmarks or excessive tissue.
Prosthetic limb or joint (near insertion point).
Patients with chlorhexidine sensitivity/allergy, use 10% povidone-iodine swab

Patient Factors & Considerations

Existing trauma at the insertion site.
Infection at the insertion site/in targeted bone.
Use on limbs with possible proximal fractures.
Previous orthopaedic procedure to targeted limb.

Procedure

EZIO Intraosseous Access

All relevant infection control methods to be utilised.
Prepare equipment required:
- EZ-IO driver
- Needle appropriate for patient and location
- 2% CHG 70% Alcohol swab OR
  10% povidone-iodine swab
- EZ-Stabiliser
- EZ-Connect extension set (primed with saline)
- 10mL syringe
- 10mL normal saline for injection
- Giving set
- IV fluid

Studies show that the humeral IO route is comparable to central venous drug delivery during CPR and should be selected in most non-paediatric cases. The tibial route is less effective and is de-emphisised.
Select needle. This requires clinical judgement, taking into account the size of the bone and depth of overlying tissue. The following table is only a guide:

Pink	15 mm	Minimal tissue (e.g. infant / paediatric tibia)
Blue	25 mm	Minimal tissue (e.g. adult / paediatric tibia)
Yellow	45 mm	Excessive tissue (e.g. humeral head)

Ensure needle securely seated on driver
Clean insertion site with 2% CHG 70% alcohol swab OR 10% povidone-iodine swab
Position needle at 90° to bone
Push until needle tip touches bone, ensuring at least one black line is visible on needle (5mm)
Penetrate bone cortex by squeezing the driver’s trigger and applying gentle pressure
Release the driver’s trigger and stop insertion when:
- Tibia: Immediately when a sudden ‘give’ or ‘pop’ is felt upon entry into the medullary space OR
- Humeral head: When the desired depth is obtained, typically 1 - 2cm beyond ‘give'
Remove the driver and stylet
Dispose of sharp in sharp container
Secure catheter with EZ-Stabiliser
Consider aspirating blood to assist in confirming placement
Attach the primed EZ-Connect extension set.
Consider local anaesthesia in the conscious patient
Flush the catheter quickly with 10-20mL saline (5 - 10mL in paediatrics)
Connect giving set and IV fluid as required.

Site Selection

Proximal Humerus

Place the patient's hand over the abdomen (elbow adducted and humerus internally rotated).

Palpate up the humerus (45° to the ground [the horizontal plane]) until you feel the surgical neck; the point at which you will begin to feel the 'ball' of the humerus.

Palpate the insertion site 1 to 2cm above the surgical neck, into the greater tubercle (‘ball’ or humeral head).

Once the insertion site has been prepared, insert the IO needle, angled slightly downwards and at 45° to the ground (horizontal plane).

Alternative method for siting humeral head for IO access

Proximal Tibia

Adult or Large Paediatric Patient

Extend leg out straight.
Palpate the tibial tuberosity. Locate the medial plateau site by moving two finger widths below the tibial tuberosity and then two finger widths medial along the flat aspect of the tibia.
Insert needle 90° to bone.

Vasc - IO6

Newborn, Infant or Paediatric Patient

Extend leg out straight.
Palpate the tibial tuberosity. Locate the medial plateau site by moving one finger width below the tibial tuberosity and then one finger width medially along the flat aspect of the tibia.
Insert needle 90° to bone.

Vasc - IO5

Success

Ability to administer medications as per specific guidelines.

Discontinue

If multiple failed attempts, consider whether vascular access is necessary to manage current patient presentation.

Additional Information

Potential complications of attempting intraosseous access:

Compartment syndrome.
Damage to paediatric growth plates.
Local tissue infection.
Misplacement.
Osteomyelitis.
Pain (particularly infusing fluid in the conscious patient).

EZIO

Battery indicator

The drivers are equipped with a power indicator light that illuminates when the driver trigger is deployed. This light illuminates green when the battery has sufficient power and blinks red when the driver needs to be replaced.

Manual insertion

Rotate clockwise/counter-clockwise while applying gentle, moderate, steady downward pressure without rocking the needle set. Allow rotation and pressure to penetrate the bone cortex, not excessive force. Stop insertion when a change in resistance is felt as a "give" or "pop" indicating entry to medullary space in pediatric patients. In adult patients, advance needle set approximately 1-2cm after entry into medullary space (felt as a change in resistance); in the proximal humerus for most adults, the needle set should be advanced 2 cm or until hub is flush or against the skin.

Depth markers

Blacklines The EZ-IO® Catheter is marked with black lines starting approximately 5 mm from the hub. This should be used as a “depth gauge” to to determine if the needle set is the correct length for the patient prior to powering the needle set past the outer cortex and into the medullary space. Indications that the needle set is not long enough include the following: the needle set does not reach bone or no black lines are visible above the skin with the tip of the needle set touching bone.

Arrow EZ-IO® training app, available on personal mobile devices:

References

Cadogan, M. (n.d.). EZ-IO-3. Retrieved June 27, 2016, from Life In The Fast Lane: http://i1.wp.com/lifeinthefastlane.com/wp-content/uploads/2009/09/EZ-IO-3.jpg

Teleflex. (2013). The Science and Fundamentals of Intraosseous Vascular Access. Retrieved October 01, 2020, from Teleflex: https://www.teleflex.com/global/clinical-resources/documents/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf

Teleflex. (2014). Clinical Principles of Intraossoeus Vascular Access. Retrieved June 27, 2016, from Teleflex: http://www.teleflex.com/en/usa/ezioeducation/index.html

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