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Intraosseous Access and the Emergency Nurse

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My presentation to the 2011 CENA International Emergency Nursing Conference - Adelaide South Australia.

My presentation to the 2011 CENA International Emergency Nursing Conference - Adelaide South Australia.

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  • Although largely remains underutilized
  • Resus guidelines to replace putting drugs down the ETTHow many here are allowed to insert an IO or have a competency for it
  • EZ-IOBone Injection GunFASTThe ARMY approach- becoming highly popular with defence force medics
  • So what is the IO route all about?
  • Downfall is the dwell time
  • Evidence limited for preferred site
  • 48 male patient intoxicated – struck by car – BIBA combative GCS 10Difficult IV access despite multiple attempts decision to go with IO deemed quicker and safer over other options as patient combativeEZ-IO inserted R humerus in 30secs from decision made to use itGiven Rocuronium and etomidate for RSI and sedated on fentanyl and midazalam through the IOTaken for CT contrast injected through IO a total of 155ml of fluid was injected over 65 with no change in flow rateRadiographer reported excellent quality of imagesPatient taken to ICU and had CVC inserted under ultrasound
  • 64 male –Inferior STEMI-peripheral hospital-no cath labMultiple attempts at IV all unsuccessfulThen had multiple VF arrest shocked with ROSC each timeEZIO inserted to proximal tibia – bloods sampled given 6000 IU tenectaplase and 3000 IU of heparinPt went in shock-refractory VF was given infusion of 300mg of amiodorone over 20mins30 mins post thrombolysis the ECG showed normalisation of ST elevation, no further VFHeparin infusion continued for further 12 through IO before CVC inserted.Patient D/C home 2 days later post angiogram
  • 38 female experiencing massive postpartum haemorrhagePatient became tachycardia and severely hypotensive unable to palpate BPDue to peripheral shutdown unable to get further vascular access, decision made to inserted 15g EZ-IO to humerus Patient given Gelofusion boluses through IO to restore peripheral circulation and perfusion – once stabilized right subcalvian CVC inserted and IO removedPatient survived taken to theater for hysterectomy
  • 79 women presented to PACU with haematemisis post replacement of jejunostomy tube, past medical history of end stage ovarian cancerOne hour latter patient vomited 250ml of haematemisis, became hypotensive 66/20 and tachy at 136, bloods was transfused through port as attempts were made to place peripheral IVsUnable to place peripheral Ivs and decision was made to prep for CVC and place IO in the meantime15 g inserted left tibia and patient given bouluses of epinephrine and massive transfuion pack until CVC was placed, and RSI with etomidate and succinolcholine –taken to OR for embolisationThe patient died 2 days later in ICU from another bleed from the left gastric artery
  • Personally I feel this is were IO has its biggest role to play in the prehospital cardiac arrest situationRCT – 182 patients with non traumatic out of hospital cardiac arrest – Used EZ-IOCompared first pass success between humeral, tibial and peripheral intravenous insertionsInitial attempts successful in 130 patientsFound tibia IO access to have better first pass success rate and the most rapid time to vascular accessFor cardiac arrest or unconscious patients that require immediate vascular access tibial intraosseous needle placement is advantages.
  • The aim of this study was to compare the time estabilise either IO or IV while wereing CBR suitsStudy consisted of 16 doctors and 9 nurses – had 4 scenariosOverall study showed time to estabilish IO significantly shorter compared to IV in both CBR and CBR suits

Transcript

  • 1. Intraosseous Access and theEmergency Nurse
    By: Kane Guthrie
  • 2. Objectives
    Understanding of IO and its use in the ED
    Were IO has come from
    Were we are today
    Focus mainly on use in adults
    Indications, contraindications, downfalls
    Review of literature/notable cases
  • 3. Where the IO has come from…
    Discovered by Drinker & Droan 1920’s
    Published use during World War II
    Mainly for battlefield casualty resuscitation
    Fell out with development of the IV
    Resurgence in paediatrics 1980-2000
    Manual devices
  • 4. Were we are today…
    Becoming popular in adults
    Potentially first line vascular access
    Impact and power driven devices
    Access established within 30-90secs
    94-97% first-pass success
    Resus Guidelines (Replace ETT)
    Advanced skill for nurses
  • 5. Today’s Devices
  • 6. Intraosseous Access
    Immediate alternative to vascular access
    Needle inserted into bone
    Non-collapsible vein
    Infuses into systemic circulation via bone marrow
    Equal predictable drug delivery and pharmacological effect
    Flow rates 125ml/min
    Hoskins, S. 2011. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation. Pub Ahead of Print.
  • 7. The IO vs The CVC
    Cheaper ($100 vs $300)
    Multiple insertion sites
    Less training/experience required
    Less complications/infections
    Blood sampling
    First pass success - 90% vs 60%
    Mean procedure time - 2.3 vs 9.9mins.
    Leidel, B. (2009). Is the intraosseous access route and efficacious compared to compared to convention central venous catheterization in adult patients under resuscitation in the emergency department. A prospective observation study. Patient Saf Surg. 3:24.
  • 8. Indications
    Critically ill – peripherally shut-down
    Immediate need drugs/fluids
    Limited or no vascular access
    Cardiac/respiratory arrest
    Require rapid intubation/sedation
    Behavioral emergencies
    Pre-hospital, disaster, mass casualty situations
  • 9. Contra-Indications
    Fractures/vascular trauma
    Localised infection (cellulitis/osteomyelitis)
    Prosthetic joints near site
    Previous IO attempts
    Osteoporosis
    Inability to identify insertion site
  • 10. Which Site is Best
    Proximal Humerus
    Preferred – quicker delivery
    Tibia – proximal & distal
    Popular – better first pass success
    Sternum
    Inhibits CPR access
    Ong, M. et.al. (2009). An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. American Journal of Emergency Medicine. 27, 8-15.
  • 11. Delivery
  • 12. But doesn’t it hurt???
    Insertion:
    Visual Analog score (mean 2.3-2.8)
    Comparable to peripheral IV
    Infusion:
    Visual analog score (mean 3.2-3.5)
    Proximal humerus less painful during infusion over tibia
    Insertion of 0.5mg/kg of Lignocaine prior to infusion greatly reduces pain.
    Philbeck, T. et.al. (2009). Pain management during intraosseous infusion through the proximal humerus. Annals of Emergency Medicine, 54(3):S128.
    Horton,M. & Beamer, C. (2008).Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatric Emergency Care. 24(6), 347-50
  • 13. Downfalls….
    Dwell time 24 hours!
    Very rare- but been reported:
    Osteomyelitis (0.6%)
    Extravasation – compartment syndrome (<1%)
    Subcutaneous abscess (0.7%)
    Leakage around insertion site
    Difficulty removing device
    Luck, R. (2010). Intraosseous Access. The Journal of Emergency Medicine. 39(4), 468-475.
  • 14. Notable Case’s
  • 15. Contrast through the IO!
  • 16. Case
    48 male- Intoxicated – Ped Vs Car
    Presents combative GCS 10- difficult IV
    EZ-IO inserted within 30secs to R humerus
    RSI Roc and Etomidate, Sedated –Fentanyl +Midaz
    Decision made to use IO for CT trauma series
    Had 155ml contrast/flush inserted over 65secs
    Images reported as excellent quality
    Pt followed up 6/7 no adverse effects noted
  • 17. Thrombolysis for STEMI!
  • 18. Case
    64 male – Inferior STEMI- No CATH Lab
    Difficult access - multiple episodes of VF
    EZ-IO to proximal tibia – bloods taken
    Given 6000U Tenectaplase, 3000u Heparin
    Episode shock-refractory VF given Amiodarone
    30 mins post Lysis – normalisation of ST-segments
    Continued Heparin infusion next 12 hours till CVC inserted
    D/C home 2 days later
  • 19. Obstetric Haemorrhage
  • 20. Case
    38 female – Massive PPH
    Became hypotensive/tachycardic = circulatory collapse
    Unable to get IV – IO to humerus
    Given multiple bolus fluids/bloods
    Circulation restored, CVC inserted
    Taken to OR for hysterectomy
    D/C home
  • 21. Massive Transfusion through the IO!
    • Burgert, J. (2009). Intraosseous Infusion of Blood Products and Epinephrine in an Adult Patient in Haemorrhagic Shock. AANA Journal. 77(5), 359-363.
  • Case
    79 female – E.S. Ovarian CA
    1 hour post jejunostomy tube inserted – in PACU episode of haematemesis = circulatory collapse
    IO inserted given blouses of Adrenaline, fluids, and blood products = resuscitated
    Taken to OR shows L gastric artery bleed
    Died 2 days later in ICU
  • 22. Cardiac Arrest
  • 23. The Results
    RCT – IO Vs IV in OHCA
    182 patients enrolled
    64 tibial, 51 humerus, 67 to IV - groups
    Tibial had 91% first pass success compared – 51% for humerus and 43% for IV
  • 24. Disaster Preparedness
    Resuscitation 81 (2010) 65–68
  • 25. The Results
    Aim to compared time to established vascular access wearing CBRN suits
    16 doctors, 9 nurses randomised to 4 scenarios – manikin based
    No CBRN conditions time to establish access on average 50secs for IO Vs 70secs for IV
    With CBRN IO group 65secs Vs 104secs for IV.
  • 26. Take Home Points
    If you don’t have one – get one!!!
    Simple, easy and effective!
    Train your nurses to use it.
    Consider for first line vascular access!!
  • 27. Questions
  • 28. Thank-you
    kaneguthrie@gmail.com