Arrow Ez-io

[Libby Cowen]

Positionthe patient supine with the knee flexed. Locate the tibial tuberosity and palpate approximately two fingerbreadths distal to the tuberosity, between the anterior and posterior borders of the tibia. In infants, measure one fingerbreadth below the tibial tuberosity. This is the site of insertion. (See the video below.)

Prepare the puncture site with a topical antiseptic (eg, povidone-iodine). (See the first video below.) In conscious patients, anesthetize the puncture site with 1-2 mL of lidocaine 1%. (See the second video below.)

Place one hand over the dorsal proximal tibia and below the knee for firm support. Do not place the hand underneath the knee (popliteal fossa area) during the proximal tibia needle insertion; this is a safety precaution to prevent possible lacerations and through-and-through penetration during insertion.

Hold the needle in the palm of the other hand, and relocate the insertion site. Tilt the needle caudally to avoid puncturing the epiphysis, and rotate the needle in a screwlike motion through the skin. (See the video below.) If initial skin penetration is difficult, it may be necessary to make a small incision with a scalpel prior to insertion.

Advance the needle until a sudden loss of resistance is felt. If a screw-adjustable stabilizer is present on the device, use it to make the device flush with the skin once the needle is in the correct position. A needle that stands freely and upright without support indicates correct placement. Inability to aspirate blood does not indicate improper placement.

Remove the trocar, and attach the syringe for marrow aspiration. Commonly, marrow is not aspirated upon insertion. Attach intravenous (IV) tubing to the hub, and infuse fluid. Observe the surrounding tissue for possible extravasation. (See the video below.)

Secure the line firmly after insertion. An acceptable technique is to apply tape to either side of the plastic skirt. Additional stability may be achieved by padding the plastic extension between the skirt and the hub with gauze before taping or by placing a small cup with a hole for the IV tubing over the device as an additional layer of protection. (See the video below.) Remove the intraosseous line as soon as an IV or central line is established.

Locate the landmark for the proximal tibia tuberosity to determine the insertion site (see Proximal Tibia Insertion above). Ensure that the line is properly secured prior to blood draws and fluid infusions. (See the video below.)

Although the intraosseous access devices cleared for the US market have been restricted to 24-hour use, a clinical study by Philbeck et al found that the EZ-IO could be safely kept in the adult proximal humerus and proximal tibia for as long as 48 hours. [43]

Clean the exposed sternum. Use the index finger to locate the sternal notch, and align the notch with the provided patch. (See the first image below.) Place the bone probe in the "target zone" on the patch. Ensure that the introducer is angled at a 90 angle to the skin. (See the second image below.)

Press straight and firmly in the target zone until a sudden loss of resistance is felt. (See the first video below.) Pull back on the introducer to expose the infusion tube for blood draws and infusion. (See the second video below.)

Ee Tein Tay, MD Assistant Professor of Emergency Medicine and Pediatrics, Mount Sinai Medical Center

Ee Tein Tay, MD is a member of the following medical societies: American Academy of Pediatrics, American Institute of Ultrasound in Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD, FACS Professor and Chief, Division of Vascular and Endovascular Surgery, Gonda (Goldschmied) Vascular Center, University of California, Los Angeles, David Geffen School of Medicine

Vincent Lopez Rowe, MD, FACS is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Black Academic Surgeons, Society of Black Vascular Surgeons, Southern California Vascular Surgical Society, Western Vascular Society

Disclosure: Nothing to disclose.

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

4 Berenson JR, Yellin O, Blumenstein B, et al. Using a powered bone marrow biopsy system results in shorter procedures, causes less residual pain to adult patients, and yields larger specimens. Diagnostic Pathology 2011;6:23. Research sponsored by Teleflex Incorporated.

5 Miller LJ, Philbeck TE, Montez DF, et al. Powered bone marrow biopsy procedures produce larger core specimens, with less pain, in less time than with standard manual devices. Hematology Reports 2011;3:e8.t. Research sponsored by Teleflex Incorporated.

7 Garcia G, Miller LJ, Philbeck, T, Bolleter S, Montez, D. Tactile feedback allows accurate insertion of a powered bone access device for vertebroplasty and bone marrow sampling procedures. J Vasc and Interv Radiol 2011;22(3):S86. Research sponsored by Teleflex Incorporated.

Refer to the Instructions for Use for a complete listing of the indications, contraindications, warnings and precautions. Information in this material is not a substitute for the product Instructions for Use.

Refer to the Instructions for Use for a complete listing of the indications, contraindications, warnings, and precautions. Information in this document is not a substitute for the product Instructions for Use. Not all products may be available in all countries. Please contact your local representative.

In addition to its use during pediatric cardiopulmonary resuscitation, IO cannulation should be considered in critically ill patients who require rapid access for stabilization. For example, in combat situations, IO placement has been used in critically wounded individuals (adults and children) receiving other life-saving interventions. [4, 5] Peripheral intravenous catheter insertion can be particularly challenging in infants and young children with hemodynamic instability and poor perfusion. [2, 6]

Establishing rapid vascular access can be a potentially life-saving procedure in patients with arrythmias, severe hemorrhage, septic shock, and respiratory failure. IO needle placement provides a route for administering fluids, blood products, and medications, [7, 8] as well as for the emergent administration of iodinated contrast material. [9] Additionally, IO access requires less skill and practice than central line and umbilical line placement. [10, 11] IO techniques have fewer serious complications than central lines, and they can be performed much faster than central or peripheral lines when vascular collapse is present. [11, 12, 13, 14]

IO insertion is recognized to be both safe and effective in all children and adults. [2, 15, 16] It has also been shown to be a reliable rescue technique in a helicopter emergency medical service. [17] Challenges with IO use in older patients arise from the increased difficulty of insertion through the thicker bone cortex and the smaller marrow cavity. Inability to enter the marrow may increase the likelihood of fracturing the bone. [13, 18, 19]

Despite early success with IO cannulation, its use as an alternative to traditional vascular access was limited until the 1980s. Several pediatric studies renewed interest in IO cannulation as a method to administer emergency medications during resuscitation. Encouraging results from these studies led to a greater appreciation of the utility of IO cannulation during pediatric resuscitation. In 1985, new pediatric resuscitation guidelines by the American Heart Association (AHA) recognized IO as a safe alternative to intravenous (IV) access. IO cannulation subsequently became part of the pediatric advanced life support (PALS) training (AHA, 1986). To reflect the growing acceptance of IO use to establish vascular access, the 2010 AHA PALS guidelines upgraded their IO access recommendation to "the initial vascular access in cases of cardiac arrest" (class 1, level of evidence C), thereby equating IV and IO access for resuscitative purposes. [24] Although IO use was initially recommended only in children younger than 6 years, the most current guidelines for adult and pediatric cardiopulmonary resuscitation support the use of IO techniques in patients of all ages. [2, 3, 15]

The red and yellow marrow of human long bones contains a rich network of vessels that drains into a central venous canal, emissary veins and, ultimately, the central circulation. Within the epiphysis (proximal and distal end) of the medullary space of long bones, is an extensive network of blood vessels which extend both vertically (Haversian canals) and horizontally (Volkmann canals). [14] This abundant venous network can function as a noncollapsible venous access route when peripheral or central venous access have failed. [25] This is particularly important in patients in shock or cardiac arrest, when peripheral veins can collapse and blood is shunted to the core due to compensatory peripheral vasoconstriction. [14] Intraosseous (IO) access via manual needles or battery powered IO drivers (see the following images) allows direct access to the medullary bone marrow and venous drainage of long bones. Establishing an IO route for vascular access allows medications and fluids to enter the central circulation within seconds.

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