EZ-IO UPDATE for Buncombe County EMS
The use of intraosseous (IO) access devices has become a vital tool in the pre-hospital environment over the last 4-5 years. In situations where intravenous access is difficult or is unable to be obtained, IO access is able to provide a route for fluid and medication administration. This online course will review the use of the EZ-IO system, including indications, contraindications, and the “5 Rights” of the EZ-IO. Content of this course is based off the current recommendations from Vidacare and the protocols for Buncombe, Madison, and Yancey Counties.
Intraosseous access is indicated for adults and pediatrics anytime vascular access is difficult to obtain in emergent, urgent or medically necessary cases. These cases include, but are not limited to: cardiac arrest, respiratory failure/arrest, multisystem trauma with hypovolemia, or vascular collapse due to severe dehydration.
The use of the EZ-IO device is contraindicated in the following situations:
- 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
- History of osteogenesis imperfecta
- Local protocol limits the use of the EZ-IO system to pediatrics above 3 kg. If a pediatric patient does not fit into or above the pink section of the Broslow Tape, use the manual needle.
Vidacare had developed the 5 Rights of the EZ-IO in order to help users remember key items to successful placement. These 5 Rights are:
- The Right Site
- The Right Needle
- The Right Pain Management
- The Right Flush
- The Right Amount of Pressure
When these 5 rights are followed, proper placement and flow are more likely to be achieved. We will look at each item in detail.
THE RIGHT SITE
Once you have decided that a patient will benefit from the EZ-IO, the first step is to identify the right site for needle placement. The FDA has approved 3 sites that the EZ-IO can be placed: the Proximal Humerus, Proximal Tibia, and the Distal Tibia. It is important to properly locate these sites to ensure successful insertion.
The proximal humerus insertion site is located directly on the most prominent aspect of the greater tubercle. Ensure that the patient’s hand is resting on the abdomen and that the elbow is adducted (close to the body). Slide thumb up the anterior shaft of the humerus until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm (depending on patient anatomy) above the surgical neck is the insertion site. This is the preferred site for patients who are responsive to pain. Once the insertion is completed secure the arm in place to prevent movement and accidental dislodgement of the IO catheter. When selecting the proximal humerus, Vidacare recommends the 45 mm needle on patients >40kg (90lbs).
The proximal tibia insertion site is approximately 2 cm below the patella and approximately 2 cm medial to the tibial tuberosity. Remember; “Big Toe IO” means to look on the big toe side of the leg for the tibial plateau (the flat spot).
The distal tibia insertion site is located approximately 3 cm proximal to the most prominent aspect of the medial malleolus (depending on patient anatomy). Place one finger directly over the medial malleolus; move approximately 3 cm proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. Again; “Big Toe IO”.
THE RIGHT NEEDLE
Selecting the proper needle is just as important as selecting the site, if not more important. EZ-IO needles come in 3 sizes: 15mm, 25mm, and 45mm. All 3 are 15ga needles. A common misperception is that the patient’s age should be the lone deciding factor when selecting the proper length of needle. Instead of age, the amount of tissue at the insertion site should be gauged to determine the correct length of needle. One way to determine the depth of tissue is to palpate the insertion site with your finger or thumb. If the there is a small amount a tissue, a shorter needle will be needed. To get a feeling for this, press directly of one of the knuckles of your hand. If the tissue depth is excessive, similar to pressing your finger or thumb over the femur, then the longer LD needle is needed. The 45mm LD needle is recommended as the primary set for proximal humerus site for patients over 40kg (90lbs).
Another way to confirm proper needle selection is by using the 5mm mark on the EZ-IO needle set. With the needle attached to the driver, insert the needle through the skin until the tip rests against the bone at a 90 degree angle. Look at the needle to assure that you can visualize at least one black line above the surface of the skin. If you cannot see a black line, the needle set selected is too short to reach the medullary space appropriately. Remove the current Needle Set, discard and use the next larger size.
After insuring the proper site and the proper needle, it is now time to insert the EZ-IO needle. The first set is to assemble all of the require components. This includes the EZ-IO driver, selected needle set, providone-iodine swaps/preps, 2% lidocaine, and saline flushes. Inspect the needle set in sure that all components are present and are not damaged. Open the EZ-Connect tubing and attach either the lidocaine (see THE RIGHT PAIN MANAGEMENT) or a saline flush and prime the tubing. Next clean the selected site with copious amounts of providone-iodine solution. This should be done in a circular fashion starting from the center of the site moving outward in overlapping circles. Attach the needle set to the driver, this is held in place by a magnet in the needle. Remove the cap from the needle set by holding the cab and briefly activating the driver, this will unseat the cap and allow easier removal. Insert the needle through the skin at a 90 degree angle until you feel the tip of the needle touch the bone. Verify that at least one black line is visible. 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; pull the driver away from the needle, unscrew (counter clockwise) the needle from the hub and remove it, and place the needle into the sharps container. Finally, attach the EZ-Connect tubing to the needle. Confirmation of proper placement of the needle into the medullary space can be done several ways. Aspiration of morrow and/or blood into the EZ-Connect tubing can be used to confirm placement. Aspiration may not always occur, even if the EZ-IO needle has been placed properly. The absence of morrow/blood does not mean an unsuccessful placement. A firmly seated, stable needle and the ability to administer pressurized fluids without difficulty are indicators of successful placement.
THE RIGHT PAIN MANAGEMENT
It is a misconception that insertion of the EZ-IO needle is the most painful part of the procedure. Many patients and volunteers noted that the pain from insertion is similar to that of insertion of an 18ga IV needle. The majority of the pain associated with IO insertion comes from the increased pressure inside to medullary space during fluid administration. One of the advantages of IO access is the fact that the medullary space is a non-collapsible space, but it is also non-expandable. When fluid is introduced in to IO space pressure is placed on the visceral nerve endings, causing pain. Proper pain management is an important part of using the EZ-IO system. Remember, many of the procedures we doing routinely cause pain, how we treat the discomfort is as important as the procedures. If a patient is responsive to pain, administration of 40mg (2mL) 2% Lidocaine, without preservatives or epinephrine, prior to flushing with saline will help reduce pain associated with increased pressure in the medullary space. Lidocaine provides a local anesthetic effect to the area of insertion. In order for this to happen, the administration must be done slowly, over 15-30 seconds.
THE RIGHT FLUSH
One of the most common mistakes made is IO placement is not properly flushing the IO site prior to administering fluids and/or medications. The interosseous space is filled with a morrow that is held in place by a thick fibrin mesh. This fibrin mesh must be displaced in order to achieve optimum flow. The EX-IO must be flushed with 10mL of saline, rapidly, to displace the fibrin network. The flush may have a similar sensation as pushing D50 thru an IV site. After flushing with a 10mL flush, the IO should flow easily and rapidly. Occasionally, additional saline flushes may be needed. If an IO site is not flowing properly, flush the site with another 10mL saline flush to see if flow improves. Remember: NO FLUSH = NO FLOW.
THE RIGHT PRESSURE
The final step in insuring successful EZ-IO insertion is using the right amount of pressure to maintain proper fluid flow. The pressure inside the medullary space is approximately 1/3 that of the patient’s mean arterial pressure. In order to achieve the best flow rate, the pressure of the fluids being administered must be higher than the pressure in the IO space. Using a pressure infuser is the easiest way to increase fluid pressure. Fluids can also be delivered using a syringe.
Removing EZ IO Needle
To remove the EZ IO needle from the patient, first clamp the EZ-Connect tubing and disconnect it from the EZ IO needle. Attach a lure lock compatible syringe to the EZ IO needle; this is used as a handle to aid in removal. Rotate the syringe and needle clockwise, to release the needle from the cortex, and pull straight out while continuing to rotate clockwise. DO NOT ROCK THE NEEDLE BACK AND FORTH. After rotating several times the needle should come completely out. There may by minor bleeding at the insertion site. Clean and dress the insertion site with an adhesive bandage or similar dressing. The EZ IO needle must be removed from the patient within 24 hours.
If you ever have questions or problems with the EZ IO system, Vidacare provides a 24 hour “hot line” to assist with clinical issues. In every EZ IO needle set there is a fluorescent colored wrist band that should be attached to the patient. This wrist band alerts the receiving staff that the patient has an IO in place and when it was place. The 1-800 “hotline” number is also on the wrist band.
The placement of an IO needle can be both safe and beneficial for patients in need of emergent vascular access. Remember the 5 Rights of EZ IO Placement:
- The Right Site
- The Right Needle
- The Right Pain Management
- The Right Flush
- The Right Amount of Pressure
By remembering these rights, every placement will be a successful placement. Special thanks to the Vidacare Clinical Education staff for providing the most up to date clinical information. Additional training on the EZ IO system from Vidacare can be found at: