EZ IO for Buncombe County Paramedics
The EZ IO device consists of a battery powered driver, a special needle assembly, a right-angle extension tubing (“EZ Connect”), and a wrist band. We’ll look at the apparatus in a moment, let’s review the protocol stuff first…
The protocol indications are:
- Patients where rapid, regular IV access is unavailable with any of the following;
- cardiac arrest / respiratory failure / respiratory arrest
- multi-system trauma with severe hypovolemia
- severe dehydration with vascular collapse and/or loss of consciousness
Contraindications are:
- Fracture proximal to proposed insertion site
- History of Osteogenesis Imperfecta (“brittle bone disease”)
- Current or prior infection at the proposed site
- Previous IO insertion or joint replacement at the proposed site
Protocol Review
Early 20’s patient trapped in an MVA, you can’t get to a good IV site, you suspect bilateral femur fractures, chest injury and the GCS is 8 and dropping.
The tibial sites are not available to you because there’s a fracture proximal to the tibia site on both sides. You’ll have to use the humeral head site. What if you noticed a skin infection or a scaly rash all around the shoulder where you’re thinking about placing the IO? Right; you can’t place the needle through a skin infection and we’re going to assume that a scaly rash is an infection. Hopefully the other shoulder is accessible and without contraindications.
The Apparatus
All the stuff is this soft-side case with a quick reference card in the side.
Assembling the Equipment
Prime the right-angle EZ Connect with Lidocaine. Lidocaine is used to provide some anesthetic to the pressure-sensitive nerves inside the bone. The insertion is essentially painless, infusion can cause severe pain. Lidocaine first is important!
The needle and driver shaft are magnetic. With the cap open on the shuttle, direct the driver shaft to the needle attachment and the needle will magnet to the driver out of the shuttle.
Twist the needle guard off the needle assembling by turning guard clockwise. If you turn counter-clockwise the needle may separate from the hub. If that happens just screw it back on.
Sites
Proximal Tibia; (Primary)
Two finger widths below (distal) the patella or tibial tuberosity. Find the “flat spot” on the medial aspect of the tibial shaft. Remember; “Big Toe IO” means to look on the big toe side of the leg for the tibial plateu (the flat spot).
Distal Tibia; (Secondary)
Two finger widths above (proximal) the ankle bone on the medial side. Again; “Big Toe IO”
Humeral Head
The greater tubercle is located by having the patient place their hand on their belly button and relax their shoulder and elbow against the stretcher or the back of a chair. Draw a straight line between the coracoid process and the acromion. Complete the drawing of a perfect triangle by using the previous line as the base of the triangle and extending the “point” of the triangle over the humeral head. The site is at the downward point of the triangle.
Insertion Procedure
With the site chosen and properly cleaned
- Penetrate the skin the bone without running the driver.
- Assure the 5mm mark is visible when the needle tip has come in contact with the bone. This assures there will be enough needle length to reach the marrow cavity. If the 5mm mark is not visible do not proceed, the needle is not long enough! (Longer needles will be available soon for patients with thick dermal tissue.)
- Run the driver constantly with mild pressure for adult patients, no pressure with pediatric patients. With peds, let the weight of the driver do the work!
- Stop the driver when you feel the “pop” into the intraosseous space.
While holding the hub in place against the skin
- Pull the driver away from the needle (it’s a magnetic connection).
- Unscrew (counter clockwise) the needle from the hub and remove it.
- Put the needle in a sharps container.
- Look for these signs of successful insertion
- blood in the hub
- catheter stable in the bone
- Connect the EZ Connect adapter you flushed with Lidocaine earlier.
- Aspirate a small amount of blood to confirm placement.
- Administer 2-4 ml of 2% Lidocaine, flush should be easy.
- A second flush may be needed on larger patients; do the second flush with saline.
- Check for any leakage or extravasation or fluid gathering in extremity compartments.
- Put the arm band on the patient’s wrist.
Remember the EZ IO can be used on pediatric patients above 3 kg.
- If the patient fits on the Broslow tape the pediatric (pink) needle will work if the patient is more than 3 kg.
- Anything you can give IV and go IO.
- The EZ IO needle can be inserted without the driver by grasping it with your fingers and rotating back and forth. Don’t rock or “wobble” it while you’re doing this as it will cause the needle to be loose and not seal properly.
- To remove the needle, attach a syringe and gently pull while turning clockwise.
More Information
- Link to manufacturer’s education and training website: Intraosseous Vascular Access for Rapid Injection and Infusion: Vidacare EZ-IO
- Video of actual conscious person insertions
- JEMS article