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

Today’s Devices

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.

•Application of pressure Bags improve flow rates!

Delivery

But doesn’t it hurt???

Insertion:• Visual Analog score (mean 2.3-2.8)• Comparable to peripheral IVInfusion:• 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.

•Does it cause an open fracture?

Notable Case’s

Contrast through the IO!

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

Thrombolysis for STEMI!

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

Obstetric Haemorrhage

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

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

Cardiac Arrest

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

•For OHCA tibial IO is advantages and gives excellent vascular access

Disaster Preparedness

Resuscitation 81 (2010) 65–68

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.

Intraosseous was shown to be faster in both groups!!

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!!

Questions

Thank-you

kaneguthrie@gmail.com