Intraosseous Access and theEmergency Nurse By: Kane Guthrie
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
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
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
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.
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.
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
Contra-Indications Fractures/vascular trauma Localised infection (cellulitis/osteomyelitis) Prosthetic joints near site Previous IO attempts Osteoporosis Inability to identify insertion site
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.
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
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.
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
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
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
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
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.
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!!