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1 CG13 VERSION 1.1 1/16 Guideline ID CG13 Version 1.1 Title Approved by Intraosseus Access Clinical Effectiveness Group Date Issued 01/10/2014 Review Date 31/09/2017 Directorate Authorised Staff Medical Ambulance Care Assistant Emergency Care Assistant Student Paramedic Advanced Technician Paramedic (non-ecp) Nurse (non-ecp) ECP Doctor Clinical Publication Category Guidance (Green) - Deviation permissible; Apply clinical judgement 1. Scope 1.1 This guideline outlines the provision of intra-osseous access using the EZ-IO infusion system in accordance with national and professional guidelines, and in accordance with Vidacare s EZ-IO directions for use. 2. Background and Definitions 2.1 The technique of intra-osseous infusion was described in 1922 and became increasingly popular during the second world war. The technique was later reintroduced for paediatric resuscitation. As the intra-osseous route is one of the fastest ways to establish access for the rapid infusion of fluids and drugs in the emergency situation, it has once again become a valuable additional skill for use in adults. 2.2 The EZ-IO intra-osseous access device allows for immediate vascular access within seconds, to enable the delivery of medications and intravenous fluids. The EZ-IO provides rapid, smooth entry into the bones medullary cavity, creating an immediate conduit to the central circulation utilising a cutting IO needle and small power driver.

2 CG13 VERSION 1.1 2/ The EZ-IO is authorised for use within the Trust by the following clinical grades, once trained and assessed as competent in the use of the device: BASICS/Critical Care Doctors (autonomous); Emergency Care Practitioners (autonomous); Paramedics and Nurses (autonomous); Advanced Technicians (autonomous); Student Paramedics Level 4 (Only under the direct supervision of a Doctor, Paramedic, Nurse or Advanced Technician). 3. Guidance 3.1 Each double crewed ambulance and rapid response vehicle will carry the following: 1 x EZ-IO carry bag; 1 x EZ-IO driver; 1 x Stabiliser dressing; 1 x 45mm needle; 1 x 25mm needle; 1 x 15mm needle. 3.2 The EZ-IO Power Driver can achieve approximately 500 needle set insertions under ideal conditions and contains a non-rechargable manganese dioxide lithium battery. Driver battery life expectancy may be dependent on actual usage, bone density and average insertion time. The driver does not require daily testing; the presence of a green light on the driver handle indicates adequate battery life. The light will turn red when approximately 10% of the battery life remains, providing notification of the need for a replacement.

3 3.3 Needle sets come in three lengths and are all 15g: Pink 15mm; Blue 25mm; Yellow 45mm. 3.4 Each needle set pack contains the following items: 1 x EZ-IO connect extension pack; 1 x NeedleVise sharps disposal device; 1 x patient wrist band; 1 x needle. CG13 VERSION 1.1 3/ The weight range on EZ-IO needle set packaging is a guide only, and not an absolute indication that the needle is appropriate for a particular weight. The most important check of correct needle length is the thickness of the tissue above the bone. Once the needle is inserted through skin and soft tissue and makes contact with the target bone, there must be at least one black mark on the needle still visible. The EZ stabiliser is used to secure and protect the needle once inserted. 3.6 Other equipment required: Chorhexidine/ alcohol pre-injection swab; Sterile10ml luer lock syringe for flushing; 3 - way tap; Sterile 50ml luer lock syringe; Sharps container. 3.7 Indications The EZ-IO can be used for adult and paediatric patients and is indicated if all of the following criteria are met: Actual or potentially life threatening presentation; Intravenous fluids or medications are required; Peripheral IV access cannot be established in 2 attempts or 90 seconds The IO route is the preferred route for vascular access in all cases of cardiac arrest in young children.

4 CG13 VERSION 1.1 4/ Contraindications Fracture of the bone selected for IO infusion; Excessive tissue or absence of adequate anatomical landmarks; Infection at the site selected for insertion; Previous, significant orthopaedic procedure at site (e.g. prosthetic limb/ joint); Previous IO insertion within 48 hours in the target bone (Inc. previous failed insertion attempt). Medicine may be ly administered by an alternative route, or an alternative medicine is available (e.g. the use of Glucagon instead of IV 10% glucose). All other analgesia options, including IM Morphine must have been considered prior to using the IO route for analgesia. 3.9 Cautions Extreme caution should be used when utilising intra-osseous needles with very young babies, to avoid over insertion Caution is advised when utilising intra-osseous needles with conscious patients, as both the procedure and subsequent flushing of the needle, are painful; communication regarding this procedure is essential Complications The following are potential complications which should be observed for: Dislodgement; Extravasation; Compartment syndrome; Fracture of targeted bone; Infection; Pain on use.

5 CG13 VERSION 1.1 5/ Selection of Appropriate Insertion Site IO site selection depends on patient age, size, anatomy, presenting condition, ability to locate anatomical landmarks, clinical judgment and experience. Site selection is also dependent on the absence of contraindications, accessibility of the site and the ability to monitor and secure the site The following insertion sites are authorised and listed in order of preference: Proximal Humerus (when landmarks can be clearly identified) - Preferred site for adult IO vascular access. Results in less infusion pain for conscious patients, greater flow rates, better accessibility and faster delivery of medication into the central circulation; Distal Femur Newborn, infants and children (under 6 years); Proximal Tibia Adults, newborn, infants and children (under 6 years); Distal Tibia Adult, newborn, infant and children (under 6 years) Proximal Humerus - Adults Only The insertion site is located directly on the most prominent aspect of the greater tubercle Place the patient s hand over the abdomen with elbow adducted and humerus internally rotated.

6 CG13 VERSION 1.1 6/ Place your palm on the patient s shoulder anteriorly. You should be able to feel the target area under your palm, it feels like a ball. On obese patients, you may have to push deeply Place the ulnar aspect of one hand vertically over the axilla Place the ulnar aspect of the opposite hand along the midline of the upper arm laterally.

7 CG13 VERSION 1.1 7/ Place your thumbs together over the arm. This identifies the vertical line of insertion on the proximal humerus Palpate deeply as you climb up the humerus to the surgical neck. It will feel like a golf ball on a tee the spot where the ball meets the tee is the surgical neck The insertion site is on the most prominent aspect of the greater tubercle, 1-2 cm above the surgical neck.

8 CG13 VERSION 1.1 8/ If necessary, for further confirmation, locate the inter-tubercular groove: With your finger on the insertion site, keeping the arm adducted, externally rotate the humerus 90-degrees; You may be able to feel the inter-tubercular groove; Rotate the arm back to the original position for insertion; The insertion site is 1-2 cm lateral to the inter-tubercular groove The 45mm needle set should be used for the proximal humerus site in most adults: Prepare the site by using a Chorhexidine/alcohol pre-injection swab; Remove the needle cap; Aim the needle tip downward at a 45-degree angle to the horizontal plane; The correct angle will result in the needle hub lying perpendicular to the skin; Push the needle tip through the skin until the tip rests against the bone; The 5mm mark must be visible above the skin for confirmation of adequate needle length; Gently drill into the humerus 2cm or until the hub reaches the skin in an adult Hold the hub in place and pull the driver straight off.

9 CG13 VERSION 1.1 9/ Secure the needle: Continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations. The needle should feel firmly seated in the bone first confirmation of placement; Place the stylet in a sharps container; Place the EZ-Stabilizer dressing over the hub; Attach a primed EZ-Connect extension set to the hub, firmly secure by twisting clockwise; Pull the tabs off the EZ-Stabilizer dressing to expose the adhesive, apply to the skin; Aspirate for blood/bone marrow (2nd confirmation of placement); Secure the arm in place across the abdomen Distal Femur Insertion Position Newborn, Infant, Children (Under 6 Years) and Adult The landmarks (superior patella and the distal Femur) are easily identified. The insertion site is located approximately 1-2cm above the Patella (depending on patient anatomy) on the anterior Femur and 1cm medial to avoid the Patella tendon. The use of a longer needle may be required Before insertion the leg should be immobilised to prevent flexion of the knee joint; flexion may result in dislodgement of the needle.

10 CG13 VERSION / Proximal Tibia - Newborn, Infant, Child (Under 6 Years) and Adult Adults The insertion site is approximately 1cm medial to the upper portion of the tibial tuberosity. If the tibial tuberosity cannot be identified the site is approximately 3cm below the patella (depending on patient anatomy) Newborn, Infant and Children (Under 6 Years) The insertion site is located 1cm below the tibial tuberosity or 2cm below the patella, midway between the edges of the bone, which will be dependent on the size and the age of the child In children under the age of 2, the tibial tuberosity may not be developed. If the tibial tuberosity is not identifiable, the lower aspect of the patella should be palpated. Moving 2 finger breadths (approximately. 3cm) below the patella and 1 finger breadth medial is the insertion site.

11 CG13 VERSION / Distal Tibia Adults The insertion site is located approximately 3cm proximal to the most prominent aspect of the medial malleolus. Place one finger directly over the medial malleolus; move approximately 2cm (depending on patient anatomy) proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat centre aspect of the bone. Please note: in paediatrics this distance may be slightly less Newborn, Infant and Children (Under 6 Years) The insertion site is located approximately 1-2cm (1 finger width) proximal to the most prominent aspect of the medial malleolus. Place one finger directly over the medial malleolus, move approximately 2cm (depending on patient anatomy) proximal and palpate the anterior and posterior borders of the tibia to ensure your insertion site is on the flat centre aspect of the bone.

12 CG13 VERSION / Selection of Appropriate Needle Set Depth of tissue over the site selected is key to safe and use of the EZ-IO. To measure the depth of tissue, simply depress your thumb or fingers to gauge the depth of soft tissues over the site as shown here: Depress skin tissue with thumb to gauge depth Clinical judgement should always be used to determine the appropriate needle set selection based on patient anatomy, weight and tissue depth. Once the needle is inserted through skin and soft tissue and makes contact with the target bone, there must be at least one black mark on the needle still visible. If a black line is not visible above the skin a longer needle set or alternative site should be chosen prior to penetration of the bones cortex. The 5mm mark will safely establish which needle set is appropriate for the patient. If in doubt always use one size larger.

13 CG13 VERSION / Insertion Procedure If the patient is conscious, obtain informed consent. Ensure any conscious patient is fully informed that the procedure will be painful and additionally that the insertion of any flush or additional fluid will also create additional pain. Consider the use of Entonox to reduce the pain of the procedure Assess the landmark the chosen site and rule out any contraindications to IO use at this site Assess tissue thickness at site and select the appropriate needle set Prepare infusion system: Open clamp if required; Attach female adaptor to three way tap; Prime set and purge air Prepare insertion site using aseptic technique Connect appropriate EZ-IO needle to driver, and remove and discard needle safety cap Stabilise insertion site Gently pierce the skin with the EZ-IO needle at a 90 degree angle to the bone surface until the needle tip touches the bone Before driving needle into the bone, ensure that at least one black line is visible on the needle. If no black line is visible, the patient may have excessive tissue over the selected insertion site and the needle may not reach the medullary space. Consider an alternative site or a longer needle set (3.16) Penetrate bone cortex by squeezing the driver s trigger and applying gentle downward pressure; Caution: Excessive force may cause the driver to slow down and stop. If this happens ease off and let the speed and sharpness of the needle do the work Release the driver s trigger and stop insertion when: A sudden give or pop is felt upon entry into the medullary space; The desired depth is obtained. Be aware of the potential to cause necrosis of the tissue if the catheter hub is tight to the skin of the patient.

14 CG13 VERSION / Stabilise the needle hub and remove the EZ-IO driver. Continue to stabilise the needle hub and remove the stylet by turning counter-clockwise and immediately dispose of in an appropriate sharps container or needle vise Confirm placement by one or more of the following: Stability of the catheter; Flashback of blood in the catheter or blood on aspiration. In the situation where the patient has severely compromised circulation a flash back may not be visible; Pressurised fluids flow without difficulty without any signs of extravasation; Pharmacological effects Secure the needle hub using the EZ-IO stabilizer dressing Connect primed EZ-connect extension set and infusion system Flush the catheter with 5-10mls (adults), 2-5mls (infants and small children) of saline over about 5 seconds and assess for extravasation. Advanced technicians must use pre-filled syringes. No flush = No flow - Repeated flushes may be necessary Consider reducing dosage of saline flush in conscious patients due to level of pain caused during administration. If the patient is to pain the practitioner may need to use Lignocaine for anaesthetic effect prior to the saline flush. Lignocaine must only be administered under the Trust s PGD by clinician who have been deemed competent to do so. Doctors may prescribe when present on scene Begin infusion or administration of medicines as required using a pressurised delivery system (e.g. syringe boluses). To achieve optimal flow rates in adults 300mmHg of pressure is recommended Secure the IV giving set tubing to the patients limb to reduce the risk of displacing the IO needle Write the date and time of insertion on the EZ-IO wristband and attach it to the patient to highlight that they have an IO in situ Monitor the extremity for extravasation and signs of compartment syndrome.

15 CG13 VERSION / Manual Needle Insertion In the unlikely event of driver failure, remove the power driver, grasp the needle set by hand and advance the needle set into the medullary space while twisting the needle set Needle Removal Procedure Due to the potential sharps injury, the EZ-IO must be removed when a patient is confirmed dead and remains on scene. In this situation ensure that the date and time of insertion of the EZ-IO is written on the patients skin prior to removal In cases where paediatric resuscitation is terminated and the body is transported to hospital the needle must remain in place Apply pressure to the site as needed and apply a simple dressing Document removal, and ensure the IO wristband stays on the patient for 48 hours following removal of the catheter. An IO wristband should be attached on each limb where an IO has been attempted and either failed or removed.

16 CG13 VERSION /16 4. Spare Needles 4.1 A stock of two 25mm needles must be kept on each ambulance station with an additional two 15mm and two 45mm needles held at each of the OLM base station consumable stores and on each of the Bronze Commander vehicles. 5. Cleaning and Decontamination 5.1 After each use ensure that the entire exterior surface of the power driver is cleaned using a detergent wipe. 6. Documentation 6.1 In line with Trust policy, a patient Clinical Record must be completed and annotated appropriately to identify the utilisation of the device and the placement of the IO needle. Needle removal must be documented if a deceased patient remains on scene and also where any insertion has been attempted and failed. IO insertion must also be noted on the cardiac arrest, recognition of life extinct and trauma forms where they are to be completed for the incident. 6.2 Any deviation from this guideline must be recorded, with any potential or actual adverse event reported through the incident reporting system.