The 5 Rights of Intraosseous Vascular Access Linda

The 5 Rights of Intraosseous Vascular Access Linda Arapian RN MSN MCFRS T-430 Rev, F

The 5 Rights of the EZ-IO 1. The Right Site 2. The Right Needle 3. The Right Pain Management 4. The Right Flush 5. The Right Amount of Pressure T-430 Rev, G

Who Needs an IO? • For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases. T-430 Rev, G

Maryland Medical Protocols July 2011 • INDICATIONS FOR IO – Cardiac arrest, OR – Profound hypovolemia, OR – No available vascular access, or following two unsuccessful peripheral IV attempts for patients with. . life-threatening illness or injury requiring immediate pharmacological or volume intervention, OR - In pediatric patients in cardiac arrest, go directly to IO if no peripheral sites are obvious and without having to attempt peripheral access

Contraindications • Fracture to the targeted bone • Previous orthopedic procedure to targeted limb – Prosthetic limb or joint • IO within the past 48 hours in the targeted bone • Infection at the insertion site • Inability to locate landmarks or excessive tissue T 430 Rev G

Maryland Medical Protocols July 2011 Contraindications ADDITIONAL Contraindications for IO placement: • Conscious patient with stable vital signs • Peripheral access readily available

Anatomy of Intraosseous Access Thousands of small veins lead from the medullary space to the central circulation. T-430 Rev, G

The Right Flush • The IO space is filled with a thick fibrin mesh • The medullary space must be pressure flushed to obtain maximum flow rates • 10 ml of normal saline is required for initial bolus • Flush must overcome initial resistance felt with bolus administration • More than one flush may be required to achieve maximum flow rate T-430 Rev, F

The Right Site selection is dependent upon: • Absence of contraindications • Accessibility of the site • Ability to monitor and secure the site NOTE: Sternum is NOT a site T-430 Rev, G

Maryland Medical Protocols July 2011 Acceptable Sites Manual placement • Under 6 yo – proximal tibia site • Over 6 yo – distal tibia site Mechanical • 3 -39 Kg • > 40 Kg Placement - proximal tibia - adult needle in distal tibia (needle length) - use proximal humerus if lower extremity not available - proximal humerus not approved < 40 Kg

Confirm and Clean Insertion Site T-430 Rev, G

Three Needle Sets 5 mm mark or “black line” 15 gauge 15 mm/15 g 25 mm/15 g 45 mm/15 g Length and color are the only differences between Needle Sets T-430 Rev, G

The Right Needle Selection based on: • Needle Length (15 mm, 25 mm, and 45 mm) • Soft tissue depth estimated by using your finger • Visualization of a black line after penetration of the skin • The 45 mm needle should be considered for all proximal humerus insertions – patients >40 kg • Special situations – Excessive soft tissue – Excessive muscle tissue – Edema T-430 Rev, G

Note that a black line is NOT visible above the skin Appropriate Needle Set Selection Matters! Note that the 5 mm mark is NOT visible above the skin Black line Needle Sizes Consider tissue depth PRIOR to bone insertion T-430 Rev, G

Prepare Equipment • Inspect needle packaging for damage and sterility • Open EZ-Connect and prime w/saline (or consider 2% lidocaine for patients responsive to pain) • Leave syringe attached to EZ -Connect • Open package and attach Driver to Needle Set (leave cap on needle until ready to insert) T-430 Rev, G

Remove Needle Set Safety Cap T-430 Rev, G

Stabilize Extremity Guard against unexpected patient movement. T-430 Rev, G

Insert Needle Set at a 90 o angle to the bone – insert through the skin until you touch bone T-430 Rev, G

Do not Apply Excessive Force Apply the minimal amount of pressure required to keep the driver advancing straight into the bone. T-430 Rev, G

Pediatric EZ-IO Insertion n! tio Ca u • Pediatric insertion requires a gentle grip and a soft touch il! o ec R • One size does not fit all - Consider tissue depth in needle selection • Be cautious of driver recoil - Release the trigger when you feel the lack of resistance • The EZ-Stabilizer is highly recommended on newborns and infants T-430 Rev, G

Remove Driver from Needle Set Stabilize the Needle Set while disconnecting Driver. T-430 Rev, G

Removal of the Stylet • Stabilize Needle Set and rotate the stylet counter-clockwise • Remove stylet and dispose of in approved bio-hazard sharps container • Apply EZ-Stabilizer before attaching the primed EZ-Connect T-430 Rev, G

Put Stylets Where They Belong. . . Portable sharps protector in approved biohazard containers. T-430 Rev, G

Confirm Catheter Placement Note one or more of the following: • Firmly seated catheter • Flash of blood in the catheter hub or blood on aspiration * • Pressurized fluids flow without difficulty • Pharmacologic effects * may or may not be able to aspirate blood Monitor for signs of extravasation. T-430 Rev, G

Syringe FLUSH Catheter • Prime and use extension set • Flush IO catheter with 10 ml of saline • Reminder: For patient’s responsive to pain consider 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) via the IO PRIOR to syringe flush • Some patients may require multiple syringe flushes No Flush = No Flow T-430 Rev, G

What Can be Infused? • Any medication that can be safely given through a peripheral vein can be given safely through an IO • IO and IV doses are the same T-430, Rev G

Intraosseous Usage and Pain Insertion pain is specific, and of short duration Infusion pain is general, diffuse and protracted T-430 Rev, G

Pain Management • Consider IO 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) for patients responsive to pain prior to flush. Follow institutional protocols/policies. • Medications intended to remain in the medullary space, such as a local anesthetic, must be administered very slowly until the desired anesthetic effect is achieved. *Physician must determine appropriate dosage range T-430 Rev, G

Maryland Medical Protocols July 2011 Pain Management Pain due to IO infusion: Adults administer 20 -40 mg of 2% cardiac lidocaine (1 -2 m. L 2% Lidocaine) IO Ped > 40 Kg administer 20 -40 mg of 2% cardiac lidocaine (1 -2 m. L 2% Lidocaine) IO Peds < 40 Kg Medical consultation is required

• The pressure in the medullary space is approximately 1/3 of the patients arterial pressure • Pressurizing fluids for infusion is required to obtain maximum flow rates • For aggressive fluid resuscitation a rapid infuser may increase flow rates Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered. T-430 Rev, F

Infuse Fluids with Pressure Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered. T-430 Rev, G

Clinical Support • Wrist band • 24 hour Emergency Line • 1 -800 -680 -4911 • www. vidacare. com • Web Feedback form T-430 Rev, G

EZ-IO Removal Maintain axial alignment – DO NOT rock the syringe Rotate syringe clockwise while pulling straight back Back the EZ-IO catheter out of patient while stabilizing the extremity. T-430 Rev, G

Cleaning & Disinfecting • Wipe clean with moistened cloth • Spray with anti-microbial solution • Momentarily depress trigger several times during cleaning • Clean around drive shaft with cotton applicator – check to ensure nothing has attached to the magnetic tip • Wipe dry • Inspect driver and return to case or replace trigger guard DO NOT SUBMERGE DRIVER AT ANY TIME T-430 Rev, G

Please review “Directions For Use” before using the EZ-IO. VIDACARE Regional Clinical Contact: Karen Hust RN MSN CEN Clinical Manager - Mid-Atlantic Territory (NJ, PA, DE, Washington DC, VA, WV, NC) 912 -308 -1839 Immediate Vascular Access… When You Need It Most exg 4. exghost. com/exchweb/bin/redir. asp? URL=http: //www. vidacare. com T-430 Rev, F

The 5 Rights of the EZ-IO Review 1. The Right Site 2. The Right Needle 3. The Right Pain Management 4. The Right Flush 5. The Right Amount of Pressure T-430 Rev, G

Questions? Please review “Directions For Use” before using the EZ-IO. T-430 Rev, G

The Right Amount of Pressure • The pressure in the medullary space is approximately 1/3 of the patients arterial pressure • Pressurizing fluids for infusion is required to obtain maximum flow rates • For aggressive fluid resuscitation a rapid infuser may increase flow rates T-430 Rev, G

“I Can ALWAYS Get a Line…” • Excessive Tissue • Diabetics • Burns • Hypertensive Crises • Dehydration • “C” before “A”? • Renal patients • Major Trauma • Sepsis • IVDA Is it adequate vascular access? T-430 Rev, G