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Circulation - Intraosseous access

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We describe the EZ-IO device which is widespread throughout Australian practice

Indications

Emergency intravenous access required

and

Peripheral intravenous access difficult or has failed

Contraindications (absolute in bold)

Proximal vascular injury (includes tibial access in suspected abdominal injury)

Fractured at insertion site

Bone pathology (osteoporosis, osteogenesis imperfecta, orthopaedic procedure at site)

Skin pathology (cellulitis or burn)

Previous intraosseous insertion at same site

Alternatives

Intravenous cannula (consider ultrasound guidance)

Central venous access

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure of placement or dislodgement (risk of extravasation with compartment syndrome)

Pain

Fracture or epiphyseal injury

Fat embolism

Infection (cellulitis, osteomyelitis)

Procedural hygiene

Standard precautions

Standard aseptic non-touch technique

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician

Equipment

Intraosseous power driver

Intraosseous needle set (size determined by depth of soft tissue overlying the bone)

Connection tubing (primed with normal saline)

Dressing

3 x 5ml syringe

5ml 0.9% saline

Pressure device (bag or pump) and line for infusion of fluids (with medications port)

Positioning (humeral: adult first line)

Internally rotate the adducted arm (palm on abdomen or arm by side with thumb medial)

Slide thumbs up the anterior shaft of the humerus until you feel the shape of the humeral head (surgical neck)

Palpate the greater tubercle of humerus 1-2cm superior to surgical neck (impalpable in young children)

Insert needle at the greater tubercle perpendicular to the skin

Positioning (proximal tibia: paediatric first line)

Identify the patella and move inferiorly to palpate the tibial tuberosity

Move another 1-2cm distally and medially (two patient finger-widths)

Insert the needle onto the flat anteromedial section of the tibia perpendicular to the skin

Medication

5ml 1-2% lignocaine without adrenaline (dose reduced for children, maximum 3mg/kg)

Sequence

Connect the selected needle size to the intraosseous device

Firmly press needle through skin and down to bone at the insertion site

Ensure a minimum of 5mm of the needle remains outside of the skin (marked by a black line)

Squeeze the trigger maintaining pressure until a sudden loss of resistance is felt (medullary space entered)

Remove the power driver

Unscrew the trocar from the catheter

Attach syringe and aspirate bone marrow (may not be possible even with correct position)

Remove syringe and attach the primed extension to catheter

Flush with 2% lignocaine over two minutes (if for non time-critical use)

Allow to sit for two minutes then rapidly flush with 5-10ml of normal saline (opens cavity, aiding flow)

Connect extension tubing to primed giving set allowing pressurised infusion of fluid

Confirm catheter placement via stability in the bone and an adequate flow rate without extravasation

Post-procedure care

Monitor site for extravasation and limb for perfusion (cease infusion if required)

Removal when vascular access obtained (traction and anticlockwise rotation to an attached Luer lock syringe)

Document (completion, technique, complications)

Tips

Use marrow aspirate for a blood sugar level and crossmatch if required

Drugs and blood products can be given via the interosseous needle

Abduction of the arm after humeral placement will dislodge needle

The most accurate determinant of correct needle selection is use of depth markings on needle

Gravity will be insufficient to drive fluid through an IO, a pressure bag or pump is required

Estimated needle type by weight:

EZ-IO 15mm (pink): neonates and small children at proximal tibia

EZ-IO 25mm (blue): children >40 kg and adults at proximal tibia, children at humerus

EZ-IO 45mm: (yellow): adults at humerus

Discussion

We recommend proximal humeral insertion for adult resuscitation due to faster infusion rates, greater proximity to the heart and reduced infusion pain compared to tibial insertion. Infusion rates equivalent to a 21g peripheral intravenous catheter (150ml/min) are typically achieved. The humeral route is however associated with greater dislodgment and may interfere with cardiopulmonary resuscitation in arrest. Providers may prefer tibial insertion depending on the specifics of the case.

We recommend distal tibial insertion for paediatric resuscitation with skeletal maturity of the humeral head reduced and greater possibility of failure and epiphyseal injury. Providers may still use the humeral head depending on the specifics of the case (e.g. abdominal trauma with risk of vascular injury proximal to the tibia).

The volume of blood that can be drawn from the IO space can be limited and not all values correlate to serum levels. We suggest it is routinely used for a point-of-care blood sugar level, and a crossmatch if required. Further samples are best taken by intravenous access, when obtained.

Any IV drug or routine resuscitation fluid can be administered safely by the IO route. Onsets of action and serum drug concentrations during cardiopulmonary resuscitation are comparable to those achieved after IV administration.

Pain on infusion is the main issue for conscious patients (not on insertion which does not require local). Lignocaine is required following insertion. Compartment syndrome is possible either due to malposition with extravasation, or failure of muscle microvasculature during infusion; monitoring of the area is required. Microscopic fat embolism is universal post IO insertion but appears clinically insignificant.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

TeleFlex. Arrow® EZ-IO® Intraosseous vascular access system: clinical education resources. n.d. Available from: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.5 – medications in adult cardiac arrest. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 13pp. Available from https://resus.org.au/guidelines/

South Western Sydney Local Health District. Interosseus device insertion. Liverpool, NSW: South Western Sydney LHD; 2014. 10pp. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/306474/liverpoolIntraosseous_Device.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Perron CE. Intraosseous infusion. In: UpToDate. Waltham (MA): UpToDate. 2019 November 25. Available from: https://www.uptodate.com/contents/intraosseous-infusion

Joanne G, Stephen P, Susan S. Intraosseous vascular access in critically ill adults--a review of the literature. Nurs Crit Care. 2016;21(3):167-177. doi:10.1111/nicc.12163

Dev SP, Stefan RA, Saun T, Lee S. Videos in clinical medicine. Insertion of an intraosseous needle in adults. N Engl J Med. 2014;370(24):e35. doi:10.1056/NEJMvcm1211371

Luck RP, Haines C, Mull CC. Intraosseous access. J Emerg Med. 2010;39(4):468-475. doi:10.1016/j.jemermed.2009.04.054

Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. doi:10.1043/2009-0381-OA.1

Lairet J, Bebarta V, Lairet K, et al. A comparison of proximal tibia, distal femur, and proximal humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model. Prehosp Emerg Care. 2013;17(2):280-284. doi:10.3109/10903127.2012.755582

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Günal I, Köse N, Gürer D. Compartment syndrome after intraosseous infusion: an experimental study in dogs. J Pediatr Surg. 1996;31(11):1491-1493. doi:10.1016/s0022-3468(96)90162-1

Nickson C. Interosseus access. Life in the fast lane. 2019. Available from: https://litfl.com/intraosseous-access/

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