Intraosseous Procedure Update
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Transcript Intraosseous Procedure Update
Vascular Access in Children:
Intraosseous Procedure Update:
“The Reasons Why”
Maryland Medical
Protocol and
Continuing Education
Maryland EMSC Program
Objectives
Discuss the indications and
contraindications for the use of
Intraosseous Access
Discuss fluids and medications that can
be administered via an IO line
Demonstrate proper site selection per
Maryland Medical Protocol
Demonstrate proper technique for
insertion and stabilization
Maryland EMSC Program
Topics of Discussion
This program will discuss/demonstrate the
following:
Indications
Contraindications
Complications
Technique
Medication and Fluid Administration
Case Studies
Maryland EMSC Program
At the end of the course the
provider will have a better
understanding of pediatric
vascular access and the use of
IO access.
Maryland EMSC Program
Vascular Access
IV : 2 large bore catheters
Upper extremity or
Lower extremity
IO: Maryland Protocol : Tibia sites
< 6 years proximal tibia
> 6 years distal tibia
upper
lower
anatomy
Maryland EMSC Program
Keys to IV Success in
Children
Have all equipment ready.
Have 2 (3) pairs of extra hands.
TELL THE TRUTH - IVs hurt.
Distract young children.
* Involve older children .
2 attempts or 90 seconds
* If child is awake and stable, ask another provider to
attempt IV insertion.
* If child is unconscious and/or unstable go to IO.
Maryland EMSC Program
IO Indications
Unavailability of vascular access or
following 2 unsuccessful IV attempts for
a patient in the following categories
Cardiac arrest
Profound hypovolemia
Life-threatening illness/injury requiring
immediate fluid or medication
Maryland EMSC Program
IO Contraindications
Conscious
patient with stable vital signs
Peripheral vascular access readily available
Fracture of the extremity
Previous IO attempts in the same extremity
Cellulitis at the intended IO site
Osteogenesis Imperfecta (OI) or other bone
disorder
Maryland EMSC Program
Potential Complications of
IO Infusion
Infection
Extravasation
of fluid
Fat
embolism
Compartment syndrome
Maryland EMSC Program
Tissue Extravasation
Maryland EMSC Program
What Can Be Administered
Through an IO
Fluids
Medications
D5W
Normal saline
D5 1/4 NSS
D5 1/2 NSS
D10W
Ringer’s Lactate
D5/Ringer’s
Blood/ volume expanders
Atropine
Bretylium
Adenosine
Calcium
D50*
Dopamine
Epinephrine Dobutamine
Lidocaine
Furosemide
Naloxone
Sodium Bicarbonate
Maryland EMSC Program
Equipment Required
IO/bone
aspirating needle
Betadine/alcohol to cleanse site
Fluid
Administration set
Stopcock/T connector (if available)
10 cc syringe
Tape and 4x4s to secure line
Pressure device
Board splint
Maryland EMSC Program
NEVER cover an
extremity that has
an IO needle
placed in it.
Maryland EMSC Program
Volume Resuscitation for
Patients in Shock
20 cc/kg Ringer’s Lactate
Bolus PUSH
REASSESS Vascular Status
Repeat 20 cc/kg Bolus RL
Radio report should include the number and
volume of boluses.
Maryland EMSC Program
“C” is for
Circulation
SHOCK :
Inadequate tissue perfusion to meet
the metabolic demands of the body
Maryland EMSC Program
Pediatric Circulation
Estimates for Resuscitation
Blood Volume = 80 cc/kg of body Weight
Weight in kg = 8 + (2 x Age in years )
Systolic BP = 80 + (2 x Age in years)
Maryland EMSC Program
“C” is for Circulation
Early signs of SHOCK in Children:
LOC : Anxious, Irritable, and Lethargic
Respiratory Rate : Increased (Tachypnea)
Heart Rate : Increased (Tachycardia)
Central Pulse : Normal
Peripheral Pulse : Weak
Skin : Pale and Cool
Capillary Refill : 3 - 5 seconds (normal = 2)
BP : Normal for Age
Maryland EMSC Program
Capillary Refill
Maryland EMSC Program
“C” is for Circulation
LATE signs of SHOCK in Children:
LOC : Unresponsive
Respiratory Rate : Very fast and then slow or none
Heart Rate : Very fast
Central Pulse : Weak
Peripheral Pulse : Absent
Skin : Very Pale, Mottled, Blue
Capillary Refill : greater than 5 seconds
BP : Low for Age (hypotension is a very late sign)
Maryland EMSC Program
Management of Shock
Airway
Breathing - 100 % oxygen
Vascular Access
IV
IO
Volume resuscitation
Initiate warming measures
Maryland EMSC Program
Maryland IO Protocol as of
7/2000
Over 6 years: distal tibia
Under 6 years: proximal tibia
Maryland EMSC Program
Lower Leg X-ray With an IO
Maryland EMSC Program
IO Placement in a Toddler
Maryland EMSC Program
Intraosseous Infusion:
Distal Tibia Site
Maryland EMSC Program
IO Placement in a
School-Age Child
Maryland EMSC Program
IO with a Stop-cock
The stop-cock
is OFF to the
syringe
Maryland EMSC Program
IO with a Stop-cock
The stop-cock
is OFF to the IV
tubing
Maryland EMSC Program
Securing an IO
Maryland EMSC Program
Case Study 1
A previously well 3 - year-old has tonic clonic
jerks separated by about 3 seconds.
ETA: 3 minutes after dispatch from the 911
center
EMS observes the child is in a postictal state.
RR is 44, pulse is 140, Temperature is 40 0 C/
1040 by report, BP is 120/76.
What would you do next????
Does this child need an IO??
Maryland EMSC Program
Case Study 2
EMS is dispatched to a pediatric call for
seizures.
A 4 -year- old child is having a seizure, and the
family reports 12 minutes of seizure activity.
The child has a history of seizures since birth.
RR is 12, pulse is 90, BP is 80/40, temperature
is 37 0 C/ 98.6 0.
What would you do next????
Does this child need an IO??
Maryland EMSC Program
Case Study 3
5 -year-old male is struck by an auto while
riding his bike. He is thrown 15 feet and lands
on his head. He has a hematoma to the right
side of his head and is unconscious and
unresponsive to verbal and painful stimuli.
He has a RR 8, Pulse 160, BP of 150/60.
What would you do next????
Does this child need an IO??
Maryland EMSC Program
IO Frequently Asked
Questions
Can a patient receive blood through an
IO?
Yes, blood can be administered through an IO.
Can blood be drawn from an IO?
Yes, lab work can be drawn from an IO.
Maryland EMSC Program
Maryland EMSC Program
Upper Extremity Vascular
Access Site
Maryland EMSC Program
Lower Extremity Vascular
Access Site
Maryland EMSC Program
Veins of the upper and
lower extremities
Maryland EMSC Program