Intraosseous Access and the Emergency Nurse

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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
  • Intraosseous Access and the Emergency Nurse

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

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