Transcript Intraosseous

Review of Current Intraosseous
Infusion Devices
Lecture Outline
• Review relevant anatomy,
indications, & contraindications
• Present background reasons for
interest in expanding use of
intraosseous (IO) line insertion in
adults
• Describe the insertion procedure for
the 4 types of currently approved IO
devices
Relevant Anatomy
Thousands of small veins lead from the bone
medullary space to the general circulation
Anatomy of long bones
Intraosseous (IO) Pressure and
Flow Rates
• With a pressure bag or IV pump, Intraosseous (IO) flow rates are
similar to IV’s through a 21-gauge needle.
• Rate of infusion that can be given IO under 300 mm pressure :
• 2 to 50 cc / min (average 10 cc / min)
• 120 to 3,000 cc / hour (average 600 cc / hour)
• Unit of blood in about 30 minutes
• Rate of infusion that can be given IO under 1 meter gravity :
• 1 to 15 cc / min (average 4 cc / min)
• Unit of blood in about 60 minutes
• Unit dose injections can be given in seconds (5cc in 3 sec)
• Rapid 10 cc syringe bolus dramatically increases IO flow rates
If no flush ---- there may be no flow !
Intrinsic IO Pressure
IO Infusion of Medication
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Which Drugs can be given ?
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Any medications that can be safely injected into a peripheral IV
can likewise be safely injected IO
•
Caution with cytotoxic drugs and hypertonic saline
What Dose ?
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Flow rates (Rapid 10 cc bolus must be given first) :
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IO medication doses are the same as those for IV injection
To maintain optimal flow, pressure of 300 mm Hg must be
applied to the infusion bag or the pump
Testing :
•
5 cc of blood can be aspirated from an IO device and placed
into a heparin-coated syringe for standard laboratory testing
Potential IO Complications
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Extravasation (leakage)
Dislodgement
Compartment syndrome
Fracture of the bone
Failure
Pain (more about this on next slide)
Infection
• Experience in thousands of children and reports on 4,000 adults
show the infection rate to be less than 0.6 % and those infections
are usually not serious (can be treated as outpatients with
removal of device)
Mortality from above complications : None
Pain from IO Insertion
• 85 % of IO patients will be unconscious
• For them, pain is not an issue
• For the conscious patient : pain is an issue
• Pain related to insertion of needle : Minimal
• May numb the skin and periosteum with local xylocaine
• Pain related to infusion of meds / fluids (visceral pressure)
• Numb the vessels by injecting xylocaine 10 mg IO
• Psychological anxiety : “You are going to do what ?”
• Talk to your patient first
Two Kinds of Pain
Related to IO Insertion
IO Contraindications
• Local Infection
• Major trauma to extremity : fractures in same limb
• Prosthesis
• Recent (24 hours) previous IO
• Vascular compromise : diabetic leg (relative
contraindication)
• Absence of anatomical landmarks
• Osteogenesis Imperfecta
IO Indications
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Cardiac arrest
Status epilepticus
Shock / Trauma
Arrhythmia
Dehydration
Burns
Drug overdose
DKA (diabetic)
End stage renal disease
Stroke
Myocardial infarction
IV access is often difficult
or impossible in these
situations.
•Coma
•Head Injury
•Anaphylaxis
•Congestive heart failure
•Dialysis
•Emphysema
•Respiratory arrest
•Hemophiliac crisis
•Sickle Cell crisis
•Pediatric shock
•Chest pain
IO is the Answer !
Anatomic Sites for IO Insertion
• Just below and medial to tibial
tubercle (preferred site for both
children and adults)
• Lower anterior femur (for children)
• Alternative sites for adults :
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Ankle medial malleolus
Anterior humeral head
Sternum
Patella
Current IO State-of-the-Art
• Universally taught as a core skill to :
• Paramedics
• Emergency physicians
• Emergency and Pediatric Nurses
• Used as a rescue IV access port in pediatrics
• Current Standard of Care for children
• So far only used sporadically in adults
• New groundswell of interest for adults in past
year
• New ACLS, PALS, ATLS, ENPC guidelines
recommend adult IO for difficult vascular access
The IO Paradigm is Changing
• No adult devices : New adult IO devices have been FDA approved.
• Fear : 15 years experience in children has dispelled the fear of
penetrating someone’s bone.
• Infection : Infection has not been a problem.
• Pain : Pain is controllable.
• Difficult : New devices make the procedure easier than starting an IV.
• No Support : Strong support from military, EMS, ER, ACLS.
• Now the “Standard of Care” : PALS, ACLS, Military .
New IO Mandate
“The use of IO devices is a promising
technique to establish emergency
access in adult patients” .
American Heart Association : 2003
ACLS Principles & Practice
Military Interest in IO’s
IV’s Are Difficult in Military
Situations
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Battlefield conditions
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Darkness with use of night vision equipment
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Hot or cold environments
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Stressful : bullets flying overhead
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Ratio of medics to troops : 1 to 40 or higher
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Medic has to carry everything he needs in his rucksack (50 kg limit)
Training & experience
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Medics are generally well trained
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But have little opportunity for experience until actually needed
Is civilian prehospital trauma care any different ?
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IV’s are just as difficult
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Many of the same factors apply
Unnecessary Deaths
• Acute hemorrhage is the major cause of Battlefield Mortality
• 50 % are killed immediately
• 50 % die within 1 hour of injury
• Improvement in care requires
• Control of bleeding
• Rapid IV administration of blood & fluids
• Most serious casualties go into shock
• Veins collapse making IV access difficult
• Average time for a medic to start an IV = 12 minutes
• Average success rate in battlefield conditions = 30 %
For 10 casualties it could take 2 hours to start IV’s
National Academy of Sciences
Institute of Medicine, 1999
F.D.A. Approved IO Devices
• Jamshidi / Illinois Sternal / Cook (manually pushed in) needles
• Mostly used for pediatrics
• F.A.S.T. Pyng (Bed of Nails)
• Designed for adult sternum
• Manually inserts 10 needles at once
• B.I.G. Bone Injection Gun (Nail Gun)
• Shoots a needle into adult tibia and other bones
• EZ-IO (Battery Powered Drill) by VidaCare Company
• Powers a hollow drill (Catheter) into the medullary space
Manually Inserted IO Needles
Manually inserted hand held
infusion needles have been
available for years.
Mostly used for
infants because
their bones are soft.
PYNG (F.A.S.T.) IO Device
F.A.S.T. Insertion Procedure
Do not attempt to use the F.A.S.T. 1
system unless you have been
formally trained, evaluated, and
authorized to perform this procedure !
F.A.S.T. Insertion Procedure
1.
Undo or cut shirt to
expose sternum.
2.
Prepare the area of the
manubrium with the
iodine and alcohol
swabs included in the
package : wipe the area
1” below the sternal
notch.
F.A.S.T. Insertion Procedure
3.
Remove top half of backing
labeled 1.
4.
Place index finger in
patient’s sternal notch ;
the locating finger must
be perpendicular to the
manubrium.
Align Patch notch with
patient’s sternal notch.
5.
F.A.S.T. Insertion Procedure
6.
Secure first half of the
patch by pressing
firmly downward,
engaging the adhesive.
7.
Reaching under the
Patch, remove backing
labeled 2 and press
Patch to skin.
F.A.S.T. Insertion Procedure
8.
9.
Verify location : check that
the locating notch
matches the sternal notch
and that the Target Zone is
over the manubrium.
This is critical for safe and
effective placement of the
device.
F.A.S.T. Insertion Procedure
10. Remove Sharps Cap from the
introducer ; the clear plastic
Sharp Cap can be removed by
slightly twisting and pulling
away.
11. Place the bone probe cluster in
the target zone with its long axis
PERPENDICULAR (90 DEGREES)
TO THE SKIN.
12. Ensure needle cluster is within
the target zone.
F.A.S.T. Insertion Procedure
13. Press the Introducer into
the target zone with firm
and increasing force, until
a distinct release of the
Introducer handle is heard
and felt.
14 •
The force must be applied
in line with the long axis of
the Introducer ; the forearm
and elbow must be in line
with Introducer’s axis.
15 •
After release pull straight
back to remove the
Introducer.
F.A.S.T. Insertion Procedure
16.
Attach the right-angle
female connector to the
infusion tube.
17 • Attach syringe to straight
female connector and
withdraw marrow into the
Infusion Tube to verify
successful placement.
18 • Remove and discard
syringe.
F.A.S.T. Insertion Procedure
19.
Place the protector
dome over the patch and
press down firmly to
engage the velcro
fastening.
F.A.S.T. Removal Procedure
20 •
Remove the Protector Dome from the Target
Patch.
21 •
Disconnect the Infusion Tube from the right
angle female connector on the Patch.
Do not pull on the infusion tube to
remove it !
F.A.S.T. Removal Procedure
(Continued)
1•
Insert the Remover into the
Infusion Tube : keep the
Infusion Tube straight out (90
degrees) from the patient.
2•
Advance the remover till you
hear or feel it enter the threads
in the proximal tip of the
infusion tube.
3•
Turn the remover clockwise
until it stops.
4•
Pull straight out on the remover
to remove the infusion tube.
The B.I.G™ IO Device
Pediatric B.I.G : 18
Gauge
Adult B.I.G : 15 Gauge
FDA Approved
FDA Approved
B.I.G. Technique of Insertion
Use a povidone iodine tincture sponge to clean
the selected site for injection.
Position the front of the B.I.G™ at the selected
site, holding and pushing firmly on the rear of
the instrument.
B.I.G. Insertion Sequence
1
.
4
2
5
3
B.I.G. Technique of Insertion
Position the BIG with one
hand to the site
and pull out the Safety
Latch with the other hand.
B.I.G. Technique of insertion
Trigger the BIG at 90º
to the surface.
B.I.G. Technique of Insertion
Remove the BIG.
Pull out the stylet (trocar).
Technique of insertion
Fix the cannula with the
Safety Latch.
Connect IV Set with a stopcock and
flush with 1 mg / kg for IO local
anesthetics.
The “EZ-IO” Drill Device
“Making difficult IV access
a thing of the past”
Jointly owned and developed by
The University of Texas Health Science Center
&
VidaCare Corporation
.
Univ. of
Texas in
San Antonio
Dr. Larry Miller who
developed the EZ-IO device
EZ-IO Description
• Establishes IO access simply & automatically
• Uses a hollow drill to enter the bone
• Small battery powered driver implants the needle
• Enables immediate access for all drugs and fluids
• Provides safe and easy IO access for adults
“A kinder - gentler way”
Final Design
EZ-IO
needle
and
sheath
The EZ-IO drill
Use of the EZ IO drill in a pediatric patient
EZ IO needle placed in tibia
Connector tubing for the EZ IO
How Adult EZ-IO Infusion Benefits
Emergency Medicine
• Saves time
• Takes less than 10 seconds
• IV’s take an average of 8 minutes
• One provider can treat multiple patients (Mass casualties)
• Faster transport (less time on scene)
• Improves throughput time (in the emergency department)
• Can be started en route (less scene time)
• Allows provider to handle other problems : i.e. airway, meds
How Adult EZ-IO Infusion Benefits
Emergency Medicine (cont.)
• Easy to Teach
• Short learning curve
• Technique can be taught in less than one hour
• Easy to remember (skill retention)
• High success rate builds confidence
• Huge benefit for first responders with limited critical care
exposure
How Adult EZ-IO Infusion Benefits
Emergency Medicine (cont.)
• Easy to Use
• Large target area
• High success rate (better than 97 %)
• High retention of skill level
• Intuitive procedure
• Vastly easier than starting IV’s
• May be used by Basic EMT’s
How the EZ-IO Device Benefits
Emergency Medicine
• Easy to Maintain
• Rugged : designed for the emergency environment
• Long shelf life
• Replaceable AA batteries
• Operates at wide temperature range
• Easy to clean
• Small storage space required
• Replacement parts sent overnight (24 hour support)
IO Summary
• Venous access in shock is often difficult or impossible
• Thousands die because of lack of IV fluids & drugs.
• IO has been used successfully for 65 years
• The science behind it is solid ; its’ rationale is sound.
• Inside the bone is a huge non-collapsible vein
• Functions well in shock states.
• Last 15 years in kids demonstrates IO to be Safe & Effective
• Serious side effects are very rare (less than 1%).
• IO has saved many children’s lives.
• Currently IO is vastly underutilized in adults
• IO should be considered first line treatment in serious illnesses for
children and adults .
IO Summary
• We are witnessing a major paradigm shift in IO use for
adults :
• “With adult-IO, you no longer have to worry about time
consuming and often exasperating IV access. You can
now concentrate on the more important aspects of airway
management, arrhythmias, fluid resuscitation, wound
management and scene time” .
Larry Miller M.D .