EZ-IO. Offline Reading Download as PDF. Welcome. Introduction. Anatomy and Physiology. Indications. Paediatric Considerations.

Transcription

1 EZ-IO Acknowledgement This training package was created by David Funnell, Joseph Schar, and Jordan Pring. Please direct any questions to your CSO or Team Leader. Offline Reading Download as PDF Welcome Introduction Anatomy and Physiology Indications Paediatric Considerations References

2 Summative Assessment Details Download PDF for of ine reading

3 Section 1 of 8 Welcome Welcome to the EZ-IO clinical development package. This package will introduce EZ-IO to paramedics for use in adult and paediatric cardiac arrest. It will provide an overview of IO theory and should be read in conjunction with the Intraosseous Access and Administration Clinical Practice Procedure (CPP). The CPP will elaborate on further details not included in this online package, such as how to correctly identify IO access sites, the skill of IO insertion, and medication and fluid administration through the IO site. The CPP can be accessed by the hyperlink below. Note: the CPP is applicable for paramedics (for patients in cardiac arrest) and intensive care paramedics (ICP). Intraosseous Access and Administration Clinical Practice Procedure (draft) Overview and learning outcomes: Knowledge of the anatomy & physiology applicable to IO Understand when it is appropriate to insert an IO Understand which sites are preferable in different subgroups Knowledge of contraindications A summative assessment Objective

4 Successful completion of the online package will require at least 80% correct responses to the 10 MCQ. Once issued with an authority to practice (ATP) following this online package AND completion of the Paramedic 2-day conference you will be able to use the EZ-IO when indicated in a cardiac arrest. The package will take approximately 30 minutes to complete.

5 Section 2 of 8 Introduction Intraosseous (IO) access is the insertion of a needle into a bone, which provides access to a noncollapsible venous plexus. Medications and fluids are administered via the IO access site into the bone marrow and are rapidly absorbed and transported into the central circulation. [1] Manual IO access has been used since the 1920 s with a historic use in most ambulance services in Australia since the late 1970 s. In 2014, the EZ-IO access device was introduced for ICPs. This is now being expanded to all paramedics for use during cardiac arrest. While intravenous (IV) access is the preferred method for vascular access during a cardiac arrest, [2] it is not always possible to achieve. In these circumstances, following two unsuccessful IV access attempts, IO access can provide a rapid and reliable alternative to deliver medication and fluids that may have otherwise not been able to be delivered. IO access has been demonstrated to be safe, efficient and effective for use in cardiac arrest in the pre-hospital setting. [3] All SAAS cardiac arrest medications and fluids can effectively be administered through the IO access site. IO insertion is not a replacement for IV access; rather it allows emergency access when IV attempts fail. IO needles do not constitute a definitive therapy and should be viewed as a rescue device. Often once resuscitation has commenced, accessing an IV becomes easier and is recommended as the preferred option. [2]

6 Section 3 of 8 Anatomy and Physiology The proximal and distal ends (epiphyses) of long bones contain a medullary space which houses a vast system of blood vessels. These vessels run both vertically (Haversian canals) and horizontally (Volksmann s canals). This large network allows blood and fluid to travel quickly through this component of the vascular system to reach the central circulation. IO needles are placed in the epiphyses of long bones such as the tibia and humerus where compact bone is relatively thin and there is an abundance of cancellous (spongy) bone. This area of the bone allows for easier entry through the cortex of the bone, with rapid access into the IO vasculature. The hardness of compact bone and the presence of bone spicules where the marrow is contained make this cavity a noncollapsible system, even during cardiac arrest. [2]

7 Many preclinical and clinical studies have compared drug and fluid delivery via IV and IO routes. IO injection of medications has been reported to achieve adequate plasma concentrations in a time comparable with injection through a vein. [1,5-6] This has been demonstrated both during cardiac arrest and in healthy volunteers. Fluids infused via the IO route can gain access to the central circulation within several seconds to less than 2 minutes, even during CPR. [7] Although volumes of fluid will generally be administered slower through the IO than through the IV route, IO is a valuable alternative when IV access is not possible.

8 Section 4 of 8 Indications The indications for EZ-IO use for paramedics are during cardiac arrest (adult and paediatric) and only after 2 failed IV access attempts. ICPs have a broader scope of practice for IO use. There are a number of potential sites for IO access. In SAAS, the recommended sites in order of preference include: Proximal tibia Distal tibia Proximal humerus The proximal tibia is the preferred site for adults and children during cardiac arrest. It generally has a thin layer of subcutaneous fat, making landmarks (the tibial tuberosity) easier to palpate. Several studies have reported high first-attempt success rates and low rates of needle dislodgement with tibial IO access as compared with other sites. [8] During resuscitation, the tibial insertion sites are the most practical because they minimally interfere with compressions or defibrillation and reduce potential crowding around the head of the patient. [1] The proximal humerus allows for a more rapid infusion of medication and fluid into the circulation. However, since implementing the EZ-IO into practice, SAAS has received numerous reports via SLS that IO needles have become dislodged from the proximal humerus in the prehospital environment. It is thought that the manual movement of patients in the prehospital setting contributes to dislodgement from this site (especially since securing the access can prove challenging). Furthermore, the landmarks for insertion can be difficult to palpate in children <6 years of age.

9 Therefore, the proximal humerus is not used in children and is only used in adults as a last resort or in exceptional circumstances (eg abdominal or pelvic trauma). Process The Intraosseous Access and Administration CPP outlines the process for EZ-IO needle insertion, including required equipment, method, complications and infection control. Flow rates IO flow rates will vary among patients and anatomical sites. The proximal humerus allows higher flow rates than the tibial sites. Studies have shown the IO flow rates delivered under pressure to range from 200 ml/hr to 9900 ml/hr.9 During a randomized, controlled human volunteer study, mean flow rates with 300 mm Hg pressure were: 5 litres per hour through the humerus 1 litre per hour through the tibia [10] Flow rates are dependent on performing a syringe flush prior to fluid or medication administration. Failure to perform a syringe flush is a common reason for lack of flow and/or inadequate flow rates. Following confirmation of correct IO needle insertion, it is essential to flush the IO space with normal saline using a syringe before attempting to infuse medications or fluids. The syringe flush interferes with the marrow and fibrin within the medullary space, allowing for effective infusion to occur. NO FLUSH = NO FLOW. In adults, this should be at least 10ml of normal saline and 2-5 ml in paediatrics. This may require reasonable pressure initially, but avoid using extreme pressure for the flush, especially in paediatrics, as it may increase the risk of extravasation/infiltration. Other factors affecting IO flow rates include bone structure, catheter position within bone, types of fluids being infused and specific patient characteristics.

10 REMEMBER NO FLUSH NO FLOW! The primary function of IO access during cardiac arrest will be for ALS medication delivery where IV access has failed. In these situations, it is recommended that all clinicians manually inject ALS medications and flush with syringes through a 3-way tap. In some circumstances, such as hypovolaemic cardiac arrest, rapid administration of fluids may be necessary. These exceptional cases will warrant sodium chloride 0.9% to be administered via a 500 ml bag and giving set through the IO access site. This is unlikely to adequately flow without adding pressure to the bag. Sufficient pressure is required to overcome the intrinsic resistance inside the medullary space. Gravity alone will rarely generate adequate flow rates, and manually squeezing the bag is unlikely to provide consistent pressure and flow. A pressure infusion device such as the EZ-IO pressure bag is usually required to achieve an appropriate amount of pressure to enable adequate flow rates through the IO. This is demonstrated in the CPP. Great care must be taken with the use of pressure infusion bags. If an IO needle becomes dislodged from the bone and is left unnoticed, there is a real risk of fluid extravasation, leading to harmful complications such as compartment syndrome. Pressure infusion bags should only be used when absolutely necessary. Adults

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12 The Facts Proximal tibial IO is associated with higher successful insertions and lower chance of dislodgement Proximal humerus IO is associated with higher risk of dislodgement and lower successful insertion Flow rate of proximal tibial IO is 1L per hour or approximates that of a 21g cannula Flow rate of proximal humerus is 5L per hour or approximates that of a 16g cannula (both with 300 mm Hg pressure via pressure bag) Contraindications Fracture to the bone site Previous orthopaedic procedure to selected limb Prosthetic limb, joint or metal plates IO access within the past 48 hours in the selected bone Local infection, trauma or burn at the insertion site Precautions

13 History of osteoporosis or osteogenesis imperfecta increased risk of fracture Inability to locate landmarks or excessive tissue A range of further educational resources, including videos can be found on the Teleflex website.

14 Section 5 of 8 Paediatric Considerations

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16 Increased care should be taken with children, as their bones are more flexible and are softer resulting in IO needles becoming more easily misplaced or dislodged. The preferred site in children is the proximal tibia. If the needle displaces or is through the bone, infusions will collect in the soft tissue compartment and compartment syndrome can occur. This will also impact medication delivery to the central circulation. All infusions should be administered carefully by syringe in paediatrics. Pressure bags are not to be used under any circumstances.

17 Section 6 of 8 References References.pdf 39 KB

18 Section 7 of 8 Summative Assessment Details Successful completion of the online package will require at least 80% correct responses to the 10 MCQs. You are allowed three attempts for the quiz. Please speak to your team leader if you have used up all three attempts. Once you have passed the quiz, you can obtain your certificate of completion by returning to your portal. Go to quiz

19 Section 8 of 8 Download PDF for offline reading Download PDF