Advanced Boo-Boo and Owie Repair
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Transcript Advanced Boo-Boo and Owie Repair
Intraosseous Needle
Insertion
Kalpesh Patel, MD
Dept. of Pediatric Emergency
Medicine
November 22, 2006
Objectives
Understand the history of intraosseous needles (IO)
Understand the indications, risks, and benefits of IO
needle insertion
Learn to perform:
• IO needle insertion at various locations using the
manual insertion method
• IO needle insertion using new techniques
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History
Earliest reference to IO use was in 1922
First theraputic use in humans was reported in
1934
Popularized in the 1940’s for rapid access
Used widely until 1950’s when the plastic catheter
was devised
Reemerged in mid 80’s for resuscitation where IV
access was difficult
Since then, pediatric use has become more
accepted
Now used as the standard of care for emergency
access in both pediatrics and adults
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Physiology
The marrow cavity is in
continuity with the venous
circulation and functions as
a non-collapsable venous
plexus
Sinusoids serve as
transport to the central
venous channel exiting as
nutrient and emissary veins
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Physiology
The onset of action and
drug levels during CPR
using the IO route are
similar to those given
IV
• Used to infuse fluids,
blood products, and
drugs
• Can take mixed venous
blood samples for labs
such as crossmatch,
bedside tests, etc.
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Indications
When vascular access is needed in life-threatening
situations
When attempts at standard venous access fail
(three attempts or 90 seconds) or in cases where it
is likely to fail and speed is of the essence.
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Contraindications
Femoral fracture on the ipsilateral side
Do not use fractured bones
Do not use bones with osteomyelitis
Osteogenesis Imperfecta
Osteopetrosis
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Types of IO Needles
Jamshidi IO Needle
Cook IO Needle
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Illinois Sternal Iliac Needle
Sur-Fast IO Screw Tip
Needle
Equipment Required
Antiseptic prep solution
Local Anesthetic (optional in the moribund patient)
IO Needles
• 18-20 gauge spinal needle can be used as an
alternative
• In a pinch, any needle can be used, but may get
clogged with cortical bone without stylet or
trochar
Syringe
Flush solution
Gauze pads and tape
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Locations of Insertion
3 most common
locations:
• Proximal Tibia
Medial side, 1-2
cm below and
avoiding the tibial
tuberosity
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Locations of Insertion
Distal Femur
• Femur is triangular shaped.
Insert needle 1-2 cm
proximal to the superior
border of patella and medial
or lateral to anterior ridge
Distal Tibia
• 1-2 cm proximal to the
medial malleolus in the
center of the bone
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Locations of Insertion
In older children and
adults:
• Iliac crests, preferably
Anterior Superior Iliac
Spine
• Sternum
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Technique for Manual Insertion
Prep the site
Inject 1-3 ml of lidocaine into the skin and down to
the periosteum (optional when time does not permit
this)
Grasp needle in dominant hand and place it on the
site with the needle pointing away from the joint
Pinch needle with thumb and forefinger and allow
the hub to rest in the palm of your hand
DO NOT PLACE YOUR OTHER HAND BENEATH
THE SITE
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Technique for Manual Insertion
Use firm downward pressure and rotate the needle
back and forth
Feel for a sudden decrease in resistance or a
popping sound and advance the needle a few
millimeters
Remove the trochar or stylet and aspirate marrow
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Technique for Manual Insertion
Infuse fluid to determine ease of flow and no
extravasation in to soft tissues around the insertion
site
Secure the needle with goal post taping to allow
visualization of the site
If the needle fails, then insert into a new bone
because fluid will leak from the failed site
15
IO Insertion
http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=1528&id=1347
Complications
Through and through penetration
• Extravasation of fluids or medications into subcutaneous
tissue
Compartment syndrome
Subcutaneous abscess/skin necrosis
Osteomyelitis
• When an aseptic technique is used, the incidence of
osteomyelitis is less than 1%
Bacteremia
Epiphyseal injury and fracture (especially in neonates)
Fat Embolus
Bent needle
Complications are reported to occur in <1% of cases
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New Methods
F.A.S.T -1 system
Bone Injection Gun (BIG)
EZ-IO Drill
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F.A.S.T. -1 Sternal Intraosseous Device
First Access for Shock
and Trauma
Created for insertion
into manubrium of adult
sternum
May be used in older
children
http://www.pyng.com/movies/iousemovie
.html
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Bone Injection Gun
Spring loaded catheter
injected into place at a
preset depth
Comes in Adult and
Pediatric sizes
Establishes access
within 1 minute
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BIG, The Movie
http://www.ps-med.com/big/description_big01.html
EZ-IO
A battery powered
electric drill which
places the needle
quickly into place
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EZ-IO Insertion
http://www.vidacare.com/Products/index_4_29.html
Aftercare
IO’s are emergency lines and every effort should be
made to place an intravenous line after initial
resuscitation
IO’s should ideally be removed within 6-12 hours
All IO’s will eventually start to leak
IO’s can stay in for up to 48-72 hours, but after 24
hours the risk of osteomyelitis increases
dramatically
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Summary
IO’s are essentially equivalent to IV access
Should be used for emergency access
Many types of needles exist, but Jamshidi style is
preferred by most users
Preferred insertion sites include proximal or distal
tibia, or distal femur, but in older children, iliac
crests and sternum can be considered
New devices are emerging, but are not standard of
care in pediatrics yet
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Questions?
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