IO considerations Daniel Dunham
If patient is conscious Advise of EMERGENT NEED for this procedure and obtain informed consent
Rule out contraindications Fracture. Excessive tissue and/or absence of adequate anatomical landmarks. Infection at the area of insertion. Previous, significant orthopedic procedure at the site (IO in past 48 hours, prosthetic limb or joint ex. Knee replacement)
Introduction sites include Proximal Humerus (this is the preferred site & only site available to EMT-Is (and may only be used on adults)) Find this site by holding the patient s arm across chest, and feeling the area below the deltoid for bone Proximal Tibia This is the same site as is used for manual pediatric IO, the flat spot medial and below the patella Distal Tibia Above ankle, flat spot on medial aspect
Select appropriate needle size Needle gauge is the same for all needles The only difference is needle length (all are 15g) Needles are marked with weight guidelines (3-39kg for pediatric, >40 for adult) The primary concern with using a needle that is too long is keeping the needle stable following insertion, and going all the way through the bone After placing needle into skin and coming into contact with bone at least 5mm of the catheter must be visible (one black line) If the black line is not visible when the needle tip comes into contact with bone, do not continue with procedure
After selecting your insertion site Clean the site Attach needle to driver Push needle against skin until it meets bone A black line must be visible above the skin If a black line is not visible, do not continue with the procedure Now activate driver Squeeze driver trigger and apply gentle, steady pressure (use extra caution in pediatric patients; pressure should be much less, or no pressure at all). Release trigger when sudden give or pop is felt, indicating entry into medullary space.
If the driver fails 1. Remove the Power Driver 2. Grasp the Needle Set by hand and advance the Needle Set into the medullary space while twisting the needle set.
Confirm placement After removing catheter, attach PRIMED EZ-Connect (you must flush connector prior to connecting) If you plan to administer lidocaine for analgesia, it is best to prime the connector with lidocaine rather than NS and pushing lidocaine after Confirm placement with at least three of the following four methods: Stability of catheter Ability to aspirate Physiologic or pharmacologic changes Adequate flow rate Confirm that extravasation did not occur Extravasation can occur on any side of the target site; be sure check all sides Signs of extraversion include paleness, swelling, or coolness. The IO should not cause any visible changes to the site
Secure IO May be secured as any other impaled object, or you may use securing device provided. Especially important using the longest (yellow) needle, and in pediatric patients. Try not to block access to the posterior of the site, so it may be assessed for extravasation Attach arm band on the same side that the IO is placed on. Write the time the IO was placed on the arm band. This is important because the IO must be removed within 24 hours of being placed. The arm band is included with the IO needle
In patients responsive to pain Administer 20 MG Lidocaine May only be done by Paramedics requires EKG monitoring, may not be administered during bradycardia Pushing fluid is painful! Push slowly, and then wait before flushing to allow lidocaine to work
Hang fluids A pressure infuser must be used If administering a drip, be sure to check drip rate regularly as it will slow down over time. Inflate pressure infuser further, or increase flow rate.
Removal 1. Stabilize patient s extremity 2. Connect sterile luer lock syringe to hub of catheter 3. Rotate catheter clockwise wile gently pulling 4. When catheter has been removed, immediately place in appropriate biohazard container. Note: DO NOT ROCK the catheter while removing. Rocking or bending the catheter with a syringe may cause the catheter to separate from the hub!