Intraosseous Line Placement CEU
Jennifer Drexler, DO
Emergency Medicine Resident
Case Study
You respond to a call at the local all-you-can-eat buffet for a man down. On arrival you find a gentleman in his mid-60’s lying on the floor next to a booth. Family is surrounding him and a restaurant employee has started CPR as she could not palpate a pulse. You quickly re-assess the situation, and find the patient to be apneic and pulseless. The restaurant manager brings in their AED. As you commence with your primary ABC’s the patient’s wife and daughter give you a history. The patient is 67 years old with a history of a triple vessel bypass 7 years ago, high blood pressure, and some heart failure. He was starting to get up to get some dessert when he slumped back in his seat unresponsive. Family lowered him to the ground and their waitress started CPR.
Other than the patient’s obvious cardiopulmonary arrest, the physical exam does not reveal any pertinent findings. By this time the AED has been applied to the patient and no shock is advised. The patient is still unresponsive, pulseless, and apneic. The decision is made to load the patient in the rig and transport. En route your partner is working on establishing an airway, and the EMT student ride-along that is with you is performing chest compressions. Following ACLS protocols, you decide that some sort of venous access is required. You recall your recent training in the use of the EZ-IO. Quickly running through the indications for its use in your mind you decide to utilize this new tool. You locate the appropriate landmarks and insert the IO per protocol. The needle easily flushes and you immediately push a round of epinephrine and atropine. By this time you have arrived at the ED and transfer the patient’s care to the receiving team.
In the ED, resuscitation is continued including more rounds of medication through your IO line. The patient, however, does not recover any prolonged spontaneous circulation and expires in the ED. The receiving physician commends for your quick thinking in establishing IO access stating that you gave this man his best chance for recovery.
Introduction
Across the United States, there are millions of patients who suffer life-threatening emergencies every year. The standard of care for many years for these patients was the use of intravenous (IV) access for administration of life-saving medications and fluids. There are a multitude of factors that make the establishment of an IV difficult in both pre-hospital and hospital settings. One source states that paramedics encounter more than six million patients a year that they are unable to establish IV access on. This can obviously lead to increased morbidity and mortality in critically ill or injured patients.
Intraosseous (IO) access was first used therapeutically in 1934. During the 1940’s its use became more widespread, especially in battlefield medicine. However, when the IV catheter was developed the use of IO access greatly diminished. IO access has been rebounding in popularity since the 1980’s, especially in children whose still-developing bones are soft enough to permit manual insertion of the IO needle. The challenge has come in the development and use of an IO needle that is strong enough and easy enough to use in adult patients. For a variety of reasons, some outlined below, there has been a recent resurgence in the use of IO access that has spurred further research and development of battery-powered devices like the EZ-IO.
The recently updated American Heart Association (AHA) guidelines for Advanced Cardiac Life Support (ACLS) recommend the use of IO access as the first alternative to IV access in adult cardiac arrest patients. Additionally the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) have recently implemented new guidelines that recommend the use of IO infusion as the first alternative to IV access in emergency situations. Some of the reasoning behind these guidelines is that the quick establishment of IO vascular access allows the provider to concentrate on other aspects of resuscitation instead of repeatedly trying to establish an IV line.
Intraosseous access has been shown to provide venous access that is similar to that achieved with central access. Additionally, it has been shown to be a safe and effective means of delivering fluids and medications. IO medication administration is now preferred in ACLS algorithms over endotracheal tube (ETT) administration. The IO route provides a more predictable route of delivery and produces more predictable pharmacological effects than the ETT route.
Anatomy
The medullary cavities of long bones have a rich blood supply. Fluids or mediations infused into this cavity via IO access will enter the medullary venous sinusoids and flow through the central venous sinus until they drain into the central venous circulation via nutrient and emissary veins. The anatomy of the medullary cavity itself provides another advantage of IO access. Even in cases of shock when the peripheral circulation has collapsed, the venous channels in the medullary cavity remain open as the bony matrix supports them.
Figure 1. Medullary Cavity in Long Bones
Indications
In keeping with the new guidelines discussed previously, IO access is now indicated in a larger segment of the patients seen by EMS. It is a source of vascular access to be utilized when the need to provide emergent fluids or medications arises and IV access cannot be established or would take too long to establish. Exact protocols for use of the IO device differ across agencies.
Any type of fluid or medication can be infused via the intraosseous route. With the advent of the new, mechanized IO systems, obtaining IO access is now as easy in adults as it is in children. The basic utility of IO access is during a cardiopulmonary arrest or traumatic arrest when the establishment of IV access would take too long. Additional indications include life-threatening situations when attempts at establishing IV access have been unsuccessful. This can include shock, burns, status epilepticus (if other routes of medication administration are not available), or severe illness in a patient whose underlying medical condition makes IV access difficult if not impossible (e.g. dialysis, diabetes, obesity). It should be noted that IO access is not definitive therapy and that the IO needle will need to be discontinued within 24-72 hours, depending on the protocols of the institution or agency. The risk of infection, including osteomyelitis increases with the length of time the IO catheter is left in place.
Contraindications
There are relatively few contraindications to the use of IO access. Significant contraindications include the following:
- Fracture of the ipsilateral extremity due to risk of extravasation and compartment syndrome
- Previous attempt or placement of IO in the same site also due to risk of extravasation through the previous puncture site
- Osteogenesis imperfecta due to high likelihood of causing a fracture during insertion
- Osteopetrosis also due to fracture risk
- Obvious overlying infection at puncture site due to risk of spreading infection (relative contraindication)
Consider alternative sites for insertion with the following conditions
- Excessive tissue at insertion site with absence of anatomical landmarks
- Previous significant orthopedic procedure at the site
Technique of Insertion
Once the site of IO insertion is determined the basic technique is the same. The equipment needed includes the following:
- EZ-IO driver
- EZ-IO Needle Set (adult or pediatric based on patient weight)
- Alcohol or Betadine Swab
- EZ-Connect or Standard Extension Set
- 10mL Syringe
- Sterile IV Fluid
- Pressure Bag
- 2% Lidocaine (preservative free)
- EZ-IO Yellow wristband
As always, you begin with the use of approved Body Substance Isolation Equipment. Determine the indications and contraindications for use of IO access in the patient. Determine the appropriate site of insertion and prepare the site using aseptic technique. The EZ-IO driver and needle are then prepared and while the insertion site is stabilized the IO is placed. Placement is confirmed by aspirating blood and marrow and determining the stability of the needle in the bone. The primed connection is then attached and if the patient is conscious an infusion of lidocaine 2% is given. The infusion of IO fluids—not necessarily the insertion of the IO needle—has been shown to be painful in awake, conscious patients. Therefore, the administration of Lidocaine 2% is recommended prior to initiating infusion of fluids or medications through the IO. The IO catheter is then flushed with normal saline, and any soft tissue swelling or resistance to flow is noted which could indicate the IO needle is not properly inserted. After this the infusion of fluids or medications may commence. The use of a pressure bag to assist in fluid administration is recommended as the anatomy of the IO space can make flow rates seem slower than with standard IV infusion. The site is then dressed and secured. A wristband is placed on the patient to identify that they have IO access in place.
Insertion Sites
Historically, the site of IO insertion was the sternum. This has fallen out of popularity due to the obvious risk of trauma to the local vital organs. The most common site of IO insertion is the proximal tibia. This location provides a flat, wide surface with only a thin layer of overlying soft tissue. Additionally, it is a located away from the head and chest where CPR is often in progress. Additional sites for insertion include the distal tibia, distal femur, iliac sites, distal radius or ulna, and the humerus.
Figure 2: Insertion of the EZ-IO in the Proximal Tibia
Figure 3: Insertion Sites in Proximal and Distal Tibia and Distal Femur
Figure 4: Iliac Insertion Sites
Clinical Evaluation
There have been several recent studies on the ease of use and efficacy of IO access. A study quoted on the Vidacare website (makers of the EZ-IO) shows a 97% success rate in the insertion of the apparatus and the ability to give fluids or drugs through it. They reported that it took less than 10 seconds to insert to IO needle through the cortex in 94% of patients, and that it took less than 20 seconds in all of the successful cases. This study of EMS agencies was based on the use of the EZ-IO in 250 patients. Failures of placement or ability to administer fluids were attributed to dead batteries, omitting the syringe flush or pressure infusion, incorrect anatomical location, and body habitus of the patient. The use of a lidocaine flush in awake patients was reported as effective in preventing pain in 100% of the 11 patients this data was recorded for. Regarding ease of use, 54% of responding providers stated the EZ-IO was extremely easy to use and 4% stated is was extremely difficult to use. There were 7 complications reported which included 2 catheter displacements, 2 reports of “no flow”, and 3 reports of device failure (2 of which were battery related). As the use of IO access becomes more widespread there is great opportunity for further evaluation and study of the technique and the outcomes attributable to it.
Conclusion
Intraosseous access for administration of life-saving medications and fluids is now indicated as second line treatment for critically ill and injured patients. There have been great advances in the technique and devices available for IO insertion. The administration of medications and fluids by the IO route seems to be as efficacious as the alternative IV administration. In cases when seconds matter and the patient is too critical to wait for multiple IV attempts, the IO offers a promising and acceptable alternative. It remains to be seen how far reaching the changes prompted by the AHA and other organizations’ recommendations will be. By following the indications and protocols of their agency, pre-hospital providers now have another tool at their service to better care for their patients and to deliver the treatments that they need in a safe and efficacious manner.
References:
1. http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2006&PID=16056&O=Generic
2. www.nda.ox.ac.uk/wfsa/html/u12/u1210_01.htm
3. Njissne-Jordan, C. “Emergency Department Utilization and Success Rates for Intraosseous Infusion in Pediatric Resuscitations”. Canadian Journal of Emergency Medicine, 2000;2:1.
4. Eslami, P. “Intraosseous Access”. www.eMedicine.com
5. www.vidacare.com
6. www.anwers.com (figure 1)
7. Davidoff, J, et al. “Clinical Evaluation of a Novel Intraosseous Device for Adults”. www.vidacare.com
