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Intraosseous Access and Care Using the EZ IO (3.0)

Intraosseous Access and Care Using the EZ IO (3.0) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

3.0



Effective Date:
June 1, 2015
ED Manual 3.0
Original
X renewal
Page 1 of 9 Intraosseous Access
and Care using the
EZ ® IO


Intraosseous Access and Care using the EZ ® IO
UW Hospital and Clinics Emergency Department

Purpose:
Intraosseous access is considerably more expeditious than regular IV access and should be an
early consideration with known or suspected difficult venous access (ENA, 2012). To establish
intraosseous (IO) access for a critically ill and unstable adult or pediatric patient when vascular
access cannot be urgently obtained in the ED, CHETA or Medflight.

Policy:
Intraosseous (IO) access is effective for fluid resuscitation, drug administration for all age groups.
(Neumar,et al., 2010). RN placement requires a physician order. Only ED and Critical Care Transport
(CHETA and Medflight) RNs who have been trained and achieved competency can place an EZ ® IO.

The EZ-IO, made of stainless steel, cannot be present during MRI procedures. Specimens, from
marrow samples after IO insertion for lab analysis, cannot be utilized per UWHC labs.

Contraindications for IO access:
 Fracture in targeted bone
 Absence of adequate anatomical landmarks
 Infection at area of insertion site
 Previous significant orthopedic surgery at intended site (e.g. prosthetic joint/limb)
 History of bone disorders such as osteogenesis imperfecta or osteoporosis
 IO in previous 48 hours in targeted bone

Equipment
1. One EZ-IO Power Driver
2. Appropriate size intraosseous needle set based on patient size and weight:
See Figure 1(at end of policy)
a. EZ-IO 15 mm Needle-Set (pink hub): Consider for patients between 3-39 kg
b. EZ-IO 25 mm Needle-Set (blue hub): Consider for patients 40 kg and greater
c. EZ-IO 45 mm Needle Set (yellow hub): Consider for patients greater than 40 kg and/ or
with excessive tissue over insertion sites and for proximal humerus site.
3. One (1) EZ-Connect® (Tubing for IO)
4. Three (3) 10 ml syringes
5. Normal saline for flush. Note: 2% lidocaine (preservative free) for patients responding to pain
(with physician order)
6. Chloraprep application (1.5 ml)
7. Sterile 2x2 or 4x4 gauze pad
8. Infusion pump or pressure bag to infuse prescribed IV fluid


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9. Exam Gloves (to be worn by all personnel starting or discontinuing IOs)


Procedure:

Site Selection
Site selection depends on patient age, size, anatomy presenting condition and ability to locate
anatomical landmarks. The proximal humerus may allow faster delivery of medications/fluids to
central circulation (Vidacare, 2013)
EZ IO needle set insertion site options
Adults Pediatrics *
1. Proximal humerus
2. Proximal tibia
3. Distal tibia
1. Proximal tibia
2. Distal femur
3. Distal tibia
4. Proximal humerus

1. Obtain physician order for IO placement.
2. Identify landmarks and select appropriate site: (See Figure 2)

A. Proximal Tibia Site Identification (Extend leg to locate and palpate site)
1. Adults: Insertion site is approximately 3 cm (about 2 finger widths) below the patella and
approximately 2 cm (about 1 finger width) medial along the flat aspect of the tibia
2. Infants and children: Just below the patella, approximately 1 cm (about 1 finger width)
and slightly medial, approximately 1 cm (1 finger width) along the flat aspect of the tibia.
May need to “pinch” the tibia between your fingers for identifying the medial and lateral
borders.

B. Distal Tibia
1. Adults: Insertion site located approximately 3 cm (2 finger widths) proximal to most
prominent aspect of the medial malleolus.
2. Infants and children: insertion site located approximately 1-2cm (1 finger width)
proximal to the most prominent aspect of the medial malleolus.

C. Proximal Humerus
1. Adults: 45mm needle set (yellow hub) recommended for adults
a. Place patient’s hand over the abdomen (elbow adducted and
humerus internally rotated) Ensure that the patient’s hand is resting on the
umbilicus and that the elbow is adducted





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b. Place ulnar aspect of your hand vertically over axilla and ulnar aspect of your other
hand along midline of upper arm laterally. Place your thumbs together over the arm,
this is the vertical line of insertion on proximal humerus (See Figure 3)
c. Insertion site is on most prominent aspect of greater tubercle, 1 to 2 cm above the
surgical neck
d. For most adults, a 45 mm needle set (yellow hub) should be advanced until the
catheter hub is flush with the skin
2. Infants and children: Use of this site should not be used unless the proper landmarks can be
adequately located and palpated: Generally this site is not recommended for children less than
6 years of age.
a. Place patient’s hand over the abdomen (elbow adducted and humerus internally
rotated) Ensure that the patient’s hand is resting on the umbilicus and that the elbow
is adducted (similar to adult position—see picture above)
b. Place ulnar aspect of your hand vertically over axilla and ulnar aspect of your other
hand along midline of upper arm laterally. Place your thumbs together over the arm,
this is the vertical line of insertion on proximal humerus (See Figure 3)
c. Insertion site is on most prominent aspect of greater tubercle

D. Distal Femur (Pediatrics only)
ξ Stretch the leg out to ensure knee does not bend. Palpate the patella.
ξ The insertion site is just proximal to the patella (1 cm maximum) and 1 to 2 cm medial to
midline. (Vidacare, 2013)

3. Complete hand hygiene and apply non-sterile gloves

4. Prepare the skin using Chloraprep (2% CHG/70% isopropyl alcohol). Perform friction scrub for
30 seconds. Allow 30 seconds for drying. Do not touch the site after disinfecting, unless wearing
sterile gloves.

5. Flush (prime) IO tubing (EZ-Connect) with normal saline to prepare for use.

6. Connect appropriate needle set to driver. Aim toward the center of the bone at a 90-degree
angle

7. Push the needle tip through the skin until the tip rests on top of the bone. The 5 mm black
mark from the hub must be visible above the skin for confirmation of adequate needle set length.


(See Figure 1)


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If no black marks are visible on the needle, the current selected needle may be too short for the
patient size/tissue. Discontinue current needle length and apply the next longer needle length

* Clinical judgment should be used for needle set selection in pediatric patients, considering the
overlaying tissue depth (Vidacare, 2013)

8. Penetrate the bone cortex by squeezing driver’s trigger and applying gentle, consistent, steady,
downward pressure. Stop when a sudden decrease in resistance is felt (a “give or pop” is felt),
and the proper depth is obtained.

9. While holding the hub in place, twist the style off the hub with counter clockwise rotations.

10. The catheter should feel firmly seated in the bone (first confirmation of placement).
Aspiration of fluid does not guarantee the IO is in the correct location.

11. Remove stylet from catheter and immediately dispose of stylet in appropriate
biohazard sharps container. Connect the primed IO tubing to the hub and secure in place by
turning clockwise.

12. If the patient is responsive to pain: Consider use of lidocaine and obtain an order for
lidocaine. (Ensure that patient has no allergies or sensitivity to lidocaine.)
a. Consider priming extension set with lidocaine (Priming volume for the EZ-
Connect Extension set is about 1.0 mL).
b. For smaller doses of lidocaine, prime the extension set with normal saline
and consider carefully attaching syringe to the needle hub directly to
administer the lidocaine
c. SLOWLY infuse lidocaine 2% (preservative free) through the IO catheter via
the EZ-Connect (IO tubing) into the medullary space over 120 seconds and
then wait at least 60 seconds dwell time for the anesthetic to take effect.
 Pediatric Dose: EZ-IO PD 0.5 mg /kg lidocaine 2% (preservative free)
 Adult Dose: 20-40 mg lidocaine 2% (preservative free)
 May repeat one-half of original dose, as ordered, for pain management during
administration of fluids and medications

12. Stabilize the catheter hub and confirm placement by assuring that the EZ IO needle is firm in
the bone and fluid infuses without extravasation. (Swelling around site can be indicative of
extravasation)

13. Ensure the administration of a rapid SYRINGE BOLUS (flush) prior to
infusion. Failure to flush the IO catheter may result in limited or no flow (The initial flush may


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feel like pushing D50 through a 22g or 24g catheter needle.) If the flush is not performed, flow may
be obstructed due to bone marrow presence.
a. Rapid syringe bolus (flush) the catheter with normal saline
o Pediatric patient: Flush with 5 mL
o Adult patient: Flush with 10 mL.
b. Repeat syringe bolus (flush) as needed

14. Begin infusion utilizing a pressure delivery system
 IV pump or pressure bag
 Cautious use for a pediatric use: A more controlled rate is needed. Pressure bag
alone may provide this with the pediatric patient.
15. Secure site with EZ-Stabilizer® dressing or secure with gauze dressing and tape.
For lower extremity site: The leg should remain immobilized until the IO catheter is removed

16. Assess for potential IO complications:
ξ Extravasation-(Assessing area posterior to the location is important)
ξ Compartment syndrome
ξ Embolism
ξ Infection
ξ Pain (Consider need to repeat half the original dose of lidocaine, with order)

The enclosed yellow “IO bracelet” does not need to be applied to patient. This color does not conform
to the color-coded bracelets used at UWHC.

17. Documentation
Document the IO site and procedure under “Add LDA” in electronic record. Select
intraosseous and complete documentation. Note the site placed, catheter size and who placed it.
Note condition of site and extremity and patient’s response in the comment section or in your notes.
Record infused fluid on I & O Flowsheet.

See UWHC Hospital Policy # 1.44 for Removal of EZ IO.


__________________________________ ___________________________
Dr. Jeff Pothof Tami Morin RN, MS
Vice Chair of Quality & Operations Director, Emergency Services

Dr. Joshua Ross
Medical Director, Pediatric Emergency Medicine




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Reviewed by

Clinical Nurse Specialist- Emergency Department
Clinical Operations-Critical Care Transport
Clinical Operations-Emergency Department
Pediatric Emergency Education Specialist-Emergency Department
Pharmacy, Emergency Department




Figure 1

Size of patient determines needle size







25 mm
Needle Set
5 mm mark
needle set pending FDA
clearance Note that the 5 mm mark is
NOT visible above the skin
Adipose or muscle tissue thickness should be considered prior to EZ-IO insertion
45 mm
Needle Set
5 mm mark
Needle Set has not been FDA cleared


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From www.vidacare.com (Used with permission)
Figure 2 Sites for placement



Proximal Tibia Distal Tibia Proximal Humerous




Pediatrics Only






Figure 3 Locating the Proximal Humerous Site (Vidacare, 2013)




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Place the ulnar side of one hand vertically over the axilla area. Place the ulnar aspect of the opposite hand along the
midline of the upper arm laterally. Place your thumbs together over the arm. This helps identify the vertical line of
insertion along the proximal humerus.



• The insertion site is on the most prominent aspect of the greater tubercle, 1 to 2 cm above the surgical neck.
















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References
Neumar, R. W., Otto, C.S., Link, M.S., Kronick, S.L., Shuster, M., Callaway, C.W. …Morrison, L.J. (2010)
American Heart Association, (2010). Adult advanced cardiovascular life support: 2010
American Heart Association guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation, 122, S729-S767.
DOI: 10.1161/CIRCULATIONAHA.110.970988

Emergency Nurses Association, (2012). ENA Clinical Practice Guideline Synopsis: Difficult Intravenous
Access. Accessed at
https://www.ena.org/practice-research/research/CPG/Pages/Default.aspx

Langley, D.M., Moran, M. (2008). Intraosseous needles: They’re not just for kids anymore.
Journal of emergency nursing, 34 (4) 318-319.

Proehl, J.A. (2009) Emergency nursing procedures. (4th ed). St. Louis: Elsevier.

UWHC Policy 1.23: Continuous peripheral intravenous therapy

Vidacare EZ IO training and protocol material (2008). http://www.vidacare.com.

Vidacare Corporation: Science & Clinical Department (2013). Accessed at
http://www.teleflex.com/en/usa/ezioeducation/documents/EZ-IO_SAFIOVA-M-607%20Rev%20B-
PrintVersion.pdf