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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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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