APPENDIX EZ IO ADULT INTRAOSSEOUS INFUSION. Purpose: To establish guidelines for the insertion of an intraosseous catheter for patients > 40 kgs.

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1 APPENDIX EZ IO ADULT INTRAOSSEOUS INFUSION Purpose: To establish guidelines for the insertion of an intraosseous catheter for patients > 40 kgs. Indications: Any Adult patient (>40 kg) for whom you are unable to obtain peripheral vascular access after two attempts AND has one of the following: Burns Cardiac arrest Emergent medicinal therapy Respiratory compromise Hemodynamic instability (volume replacement) Shock Contraindications: Fracture of the tibia, femur or humerus Previous orthopedic procedures: i.e. knee or shoulder prostheses Extremity that is compromised by a pre-existing medical condition; i.e. tumor or PVD Overlying skin infection/trauma at the insertion site Inability to locate the 3 anatomical landmarks for insertion Excessive tissue over the insertion site Patient weight < 40 kg Any patient that may have received fibrinolytic or thrombolytic; specific to Active MI and/or Stroke Hypoglycemic patients needing D50W; EXCEPTION ONLY in Cardiac Arrest. Patient s risk for NO Transport: i.e. Unconscious Hypoglycemic (Diabetic) Equipment: EZ-IO driver EZ-IO Needle Set EZ-IO extension tubing Betadine, or Chlorprep IV setup 10 ml or 20 ml syringe Roller gauze

2 Procedure: ** No procedure should be attempted by a LPEMS medic unless that medic has received training and annual skills validation in the procedure** Locate the approved site (humeral or tibia) Cleanse site Humeral site will be initiated by PIII or Supervisor or under their immediate direction Position EZ-IO driver at a 90 degree angle to the bone. Power the EZ-IO driver through the skin to make contact with the bone. Evaluate the needle for the 5 mm mark Power the EZ-IO driver and begin insertion until the flange (base) of the EZ-IO needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the marrow cavity. Remove driver from needle set, while stabilizing needle set. Remove the stylet from the catheter. Attach the prime easy connect Confirm placement by checking for at least one of the following o Immediately flush the syringe with at least 10 ml of fluid o Catheter is firmly seated and is standing at a 90 degree angle o Note blood at the tip of the stylet o Drugs and fluid flow without difficulty Connect to fluid and begin infusion If the site does not flow, consider pressure infusion. You may relish the catheter or turn it 180 degrees. Repeat as needed. Secure EZ-IO with roller gauze to prevent accidental dislodgement. Attach wrist band to patient If failed attempt attempt a second location Notify receiving healthcare staff of IO insertion, need to remove the catheter within 24 hours, and procedure for removal. IF THE PATIENT IS CONSCIOUS AFTER INSERTION OF THE EZ-IO 1. Consider administering a bolus of mg Lidocaine 2% (1 to 2.5 ml) SLOW IV push for local vascular analgesia. This should provide pain relief for up to one (1) hour. COMPLETE AND DETAILED PROCEDURES FOR THE INSERTION OF THE EZ-IO INTRAOSSEOUS NEEDLES IN THE ADULT PATIENT ARE PRESENTED BELOW:

3 Procedure for Adult Tibia: EZ IO Adult Intraosseous Infusion (cont d) 1. Don PPE 2. Determine if EZ-IO is indicated and no contraindications are present. 3. Locate proper site for EZ-IO insertion a. Feel the front surface of the leg and locate the patella b. Locate the tibial tuberosity inferior to the patella c. Place 1 finger medial of the tibial tuberosity. Insertion location is 1 finger width medial of the tibial tuberosity. 4. Cleanse the insertion site with betadine or Chlorprep pads using accepted aseptic technique. Remember to work from inside to the outside in concentric circles. 5. If patient is conscious, inform patient of the EMERGENT need to perform procedure and that they might feel some discomfort until Lidocaine is administered. 6. Consider an anesthetic/analgesic if indicated by medical direction. 7. Prepare the EZ-IO Driver and Needle set. a. Open the cartridge and attach the needle set to the driver b. Remove needle set from the cartridge c. Remove the cap from the needle set 8. Begin insertion of the EZ-IO a. Hold the EZ-IO Driver in one hand and stabilize the leg near the insertion site with the opposite hand. b. Position the driver at the insertion site at a 90 degree angle to the bone surface. c. Power the driver through the skin at the insertion site until it makes contact with bone. d. Evaluate the EZ-IO needle for the 5 mm mark 9. Power the EZ-IO Driver and continue insertion until the flange (base) of the EZ-IO needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the marrow cavity. 10. Remove the driver from the needle set 11. Remove the stylet from the catheter. DO NOT REPLACE or ATTEMPT to recap the needle set. 12. Confirm proper EZ-IO Catheter tip position by checking for at least 1 of the following: a. IMMEDIATELY SYRINGE FLUSH with at least 10 cc of fluid b. IO catheter standing at 90 degrees and firmly seated in tibia c. Blood at tip of the stylet d. A free-flow of fluid through the needle with no evidence of extravasation. DO NOT ASPIRATE.

4 13. Connect IV tubing to EZ-IO extension set and begin infusion 14. If site does not flow, consider pressure infusion, reflush and/or rotate needle 180 degrees. Consider a combination of these procedures and repeat as necessary. 15. Dress site with roller gauze to prevent accidental dislodgement. IF THE PATIENT IS CONSCIOUS AFTER INSERTION OF THE EZ-IO 1. Consider administering a bolus of mg Lidocaine 2% (1 to 2.5 ml) SLOW IV push for local vascular and marrow analgesia. This should provide pain relief for up to one (1) hour. 2. Consider pain management for additional discomfort/pain associated with infusion. Procedure for Adult Humerus 1. Don PPE 2. Determine if EZ-IO is indicated and no contraindications are present 3. This procedure will be initiated by Paramedic III or higher 4. Locate proper site for EZ-IO insertion HUMERAL HEAD PLACEMENT a. Expose shoulder and adduct humerus (arm against supine patient s body) b. PRIMARY TECHNIQUE TO LOCATE INSERTION SITE Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect of the humeral head. Identify the greater tubercle insertion site. Pinch the anterior and inferior aspects of the humeral head while confirming identification of the greater tubercle. This ensures that the midline of the humerus is identified. Consider alternative means of placement identification to ensure proper location. c. ALTERNATIVE INSERTION SITE IDENTIFICATION i. Identify the acromion and the coracoid process by walking your index and middle finger along the clavicle to the shoulder s lateral end. ii. Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process. d. Once the insertion site has been identified, place the patient s forearm on the patient s abdomen, leaving the elbow on the ground or stretcher.

5 e. DO NOT ATTEMPT INSERTION MEDIAL TO THE GREATER TUBERCLE AT ANY TIME. 5. Cleanse the insertion site with betadine or chlorprep using accepted aseptic technique. Remember to work from the inside to the outside in concentric circles. 6. If patient is conscious, inform patient of the EMERGENT need to perform procedure and they might feel some discomfort until Lidocaine is administered. Obtain consent from patient; recall that the patient has the right to refuse. You may consider an anesthetic/analgesic if indicated by medical direction. 7. Prepare the EZ-IO Driver and needle set. a. Open the case and remove the driver and needle set cartridge b. Open the cartridge and attach the needle set to the driver c. Remove the needle set from the cartridge d. Remove the protective cap from the needle set 8. Begin insertion of the EZ-IO a. Hold the EZ-IO Driver in one hand and stabilize the humeral head near the insertion site with the opposite hand b. Position the driver at the insertion site at a 90 degree angle to the bone surface. c. Power the driver through the skin at the insertion site until it makes contact with bone. d. Evaluate the EZ-IO needle for 5 mm mark 9. Power the EZ-IO Driver and continue insertion until the flange (base) of the EZ-IO needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the marrow cavity. 10. Remove the Driver from the needle set 11. Remove the stylet from the catheter. DO NOT REPLACE OR ATTEMPT to recap the needle set. 12. Confirm proper EZ-IO Catheter tip position by checking for several of the following: a. IO catheter standing at a 90 degree and firmly seated. b. Blood at tip of the stylet c. Aspiration of marrow d. Bolus and flow fluid through the needle with no evidence of extravasation 13. Connect IV tubing or extension set and begin infusion 14. Rapid bolus site with 10 ml of NS to flush medulliary space. 15. If site does not flow, consider a reflush, pressure infusion and/or rotate needle 180 degrees. Repeat this step as necessary.

6 16. Attach Vida care wrist band 17. Dispose of Sharps Rescue of IO failure: Patients failing IO access should be rescued by: a. Tibial IO placement b. Repeated attempts at standard vascular access including peripheral lines if permitted by operational protocols c. Patients failing standard access under rescue attempt A may undergo a second IO placement attempt in the opposite humeral head or tibia. IF PATIENT IS CONSCIOUS AFTER INSERTION OF THE EZ-IO 1. Consider administering a bolus of mg Lidocaine 2% (1 to 2.5 ml) SLOW IV push for local vascular analgesia. This should provide pain relief for up to one (1) hour. Consider pain management for additional discomfort/pain associated with infusion.