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EZ-IO Clinical Principles
Clinical principles to successful IO access using EZ-IO
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Assess
What to consider
When to use
EZ-IO
Rule out
contra indications
Other
considerations
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Access | When to use IO
When to use IO
When you need to give medications or fluids immediately
Trauma
Paediatric and Adult
Shock
Shock
Neurological
Respiratory
Systemic
Cardiac arrest
Status epilepticus
Type I and Type II
Haemophiliac crisis
Arrhythmia
Stroke
Respiratory arrest
Sickle Cell crisis
Myocardial infarction
Coma
Status asthmaticus
Dehydration
Congestive heart
failure
Head Injury
Burns
Drug overdose
Rapid sequence
intubation
Chest pain
End stage renal
disease
Dialysis
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Post partum
haemorrhage
DKA (diabetic)
Access | When to use IO
When to use IO
When IV access is difficult or impossible
Pre & Post
Surgery
Anaesthesia
Any Peripheral
IV Drug
IV Fluid
Therapy
Obesity
Young & Old
72 Hour
Placement
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Access | Rule out contra-indications
Rule out contra-indications
Prosthesis
Trauma to
bone
No
Anatomical
Landmarks
Local Infection
Recent IO
in same bone
(48 hrs)
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Access | Other considerations
Other considerations prior to IO
Patient needs
Patient status
Accessibility
Post Insertion
Volume replacement
Pain receptiveness
Position of limbs
Age
Accessibility to IO site
Ability to monitor IO
site
Physique
Ability to stabilise IO
site
Ability to maintain
patient safety
Trauma to limbs
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Site
8 Sites
Proximal Humerus
Preferred site for adults
Optimal site for high flow and quick drug uptake
Awake, responsive patients
Less painful
Distal Femur
Under 6 years
Proximal Tibia
Site selection
Unresponsive
Unfamiliarity with other
sites
Unable to landmark
Dependent upon:
No previous IO in 48 hours
Absence of contraindications
Accessibility
Larger patient
Unable to access other sites
Ability to secure & monitor
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Distal Tibia
Site | Proximal humerus
Proximal humerus
Proximal Humerus
insertion site
Clavicle
Greater
Tuberosity
Surgical Neck
Humerus
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Site | Proximal humerus
Alternately
Rotate arm inwards
Hand on Umbilicus
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Site | Proximal humerus
Locate
Insertion Point
Locate
Surgical Neck
Locate
Proximal Humerus
Press hard
moving
upwards
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Site | Proximal humerus
Angle of needle insertion
Slight
Downward
Angle
45O from the
anterior
plane
45O
Anterior Plane
Indentify insertion point
Additional Guidance
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45mm needle recommend for adults
Advance 1 to 2cm after ‘pop’
Use EZ-IO Stabilizer
Site | Proximal tibia
Proximal tibia
Muscle
Femur
Knee Cap
Tibial Tuberosity
Ligament
(bony thickness below knee cap)
Tibia
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Site | Proximal tibia
Proximal tibia
Patients above 40 kg
Actual insertion
sites located
Anterior (front) view
(Fingers on tibial tuberosities)
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Site | Proximal Tibial
Proximal tibia
Patients up to 39kg
Palpate Tibial
Tuberosity
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Site | Proximal Tibial
Proximal tibia
Patients up to 39kg
If Tibial Tuberosity
cannot be palpated
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Site | Distal femur
Distal femur
Slightly off centre to
avoid tendon
Best for
children under 6
years
Note:
May need longer needle
– assess skin depth
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Midline of bone
Site | Distal tibia
Distal tibia
Midline of the bone
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Needle | Needle sizes
3 Needles
15 mm
3-39 KG
25 mm
> 40 KG
45 mm
> 40 KG
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Needle | Needle features
Black Mark
5mm
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Needle | Selection
To choose correct needle, assess skin depth
Depress skin
tissue with
thumb to gauge
depth
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Needle | Selection
Pre Drive
5mm
Black Mark
Check
Visible blood flash or aspirate
No need to see mark
post drive
25mm Needle Set
45mm Needle Set
NO
YES
Too small, mark not visible
Mark visible
Needle not touching the cortex
Needle will then go through the cortex
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Needle | Selection
Thin
Moderate
Thick
Humerus
tissue over
bone site
tissue over
bone site
tissue over
bone site
bone site
(Adults)
15
25
45
45
mm
mm
mm
mm
Insert the needle tip through skin until bone felt
Can the black 5mm mark be seen?
No
Select next size up
Yes
Insert needle
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Needle | Check
After insertion, check…
Firmly seated needle
Flash of blood
No leaking around site
No sign of extravasation
Secure using EZ Stabilizer
Use EZ Connector
EZ-IO wrist band placed
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Flush
Flush for flow
IO space
filled with
thick fibrin
mesh
Pressure
flush to
open mesh
Flush can
be painful
Pressurised
flow needed
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Flush | Flow
Maintain flow
approx 1/3 arterial pressure
Medullary space pressure can stop flow
Infusions should be pressurised for
optimal flow
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Flush
Yes
Analgesia
Recommended
Alert
Patient
?
No
Consider need for
analgesia later
Flush
with 0.9% Saline
Administer analgesia
prior to flush
10ml
Adults
Up to 5ml Children
May need to be repeated
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Comfort
Many procedures hurt...
IM Injections | IV Cannula | Central Line Insertion | Sub-cut. Infusions | IO
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Comfort
Pain sensors
Pressure sensors
Two causes of pain
Insertion
specific
short duration
Flush, Aspiration
& Infusion
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general
diffuse
protracted
Comfort
Proximal humerus
less painful
Proximal Humerus
Philbeck et al 2010
Distal Femur
Proximal Tibia
Distal Tibia
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Comfort
Administration
Consider
Local protocols
Medications intended to
remain in the medullary space,
such as a local anaesthetic,
must be administered very
slowly until the desired
anaesthetic effect is achieved
Lignocaine for patients
responsive to pain. (1)
Physician must decide the
appropriate analgesia & dose.
Give prior to IO flush. (1)
Follow institutional protocols &
policies
Repeat doses may be needed
for continued analgesia. (1)
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(1) Source: Dr Richard Hixson 2011
Please refer to reference sheet or visit www.pawz.net
Comfort | Suggested analgesia administration
Responsive to pain?
Flush the IO needle with up to 10 ml
sodium chloride 0.9% over 5 seconds
Yes
Exclude contra-indications to cardiac
lidocaine
Inject or infuse fluids and medication
under pressure as required (2)
Monitor patient clinically. Consider
additional monitoring as indicated
If discomfort reoccurs
Administer initial (higher) dose of IO
lidocaine over 1 to 2 minutes (1)
Consider repeating the subsequent (lower) dose of IO
lidocaine at a maximum frequency of once every 45 min
Flush the IO needle with up to 10 ml
sodium chloride 0.9% over 5 seconds (2)
Administer subsequent (lower) dose
of IO lidocaine over 30 seconds (1)
Inject or infuse fluids and medication
under pressure as required (2)
Source: Dr Richard Hixson 2011
Please refer to reference sheet or visit www.pawz.net
Disclaimer: Whilst every care has been taken to ensure that doses and recommendations are correct, the responsibility for final check must rest with the prescriber.© Dr Richard Hixson 2011, all rights reserved.
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Monitor
EZ-IO - What to monitor and record
Suggest adapting local policies for the management of IV cannula and CVC
lines
Site
Needle
Patient
Flow
No leaking
Is secure
Limb perfusion
Is intact
No pain from IO
infusion
Pressurised
Infusion (adults)
Signs of:
EZ-IO Band is
insitu
Expected flow
achieved
Extravasation
EZ Stabilizer is
secure
Compartment
Syndrome
Connections are
secure
Pharma effects
Infection
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Summary
What we have covered
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