Circulation Skills 5:
Intraosseous Needle Placement (Adult)
For pediatric intraosseous needle use, see Vol III—PED12 Intraosseous Vascular Access.
Manual Intraosseous Insertion in Adults
Vascular access is vital for drug and fluid administration but may be difficult to achieve in certain patients. Peripheral venous access is the preferred route for fluid and drug administration, but only if it can be achieved in a short period of time (2 minutes or less). In such cases, the intraosseous access can be the alternate method to establishing a route for fluids, and medications in adult and pediatric patients.
Indications:
- Fluid replacement in shock
- Rapid vascular access
- Cardiac arrest
- Acute respiratory distress
- Any time rapid vascular access is required (all forms of shock)
Contraindications:
- Inability to locate landmarks
- Fracture or recent surgery of the extremity to be used
- Infection over the insertion site
- Severe osteoporosis, tumor of the leg, or knee replacement
Various intraosseous devices are available for use in adults, including the Illinois Sternal/Iliac Aspiration Needle (16-gauge), the Jamshidi® Bone Marrow Needle (15-gauge), the EZ-IO®, and the Bone Injection Gun™ (BIG). These devices can be used in the tibia just below the tibial tuberosity and the distal femur. Some may be used in the humeral head and the manubrium. (Know your device.) When inserting an intraosseous (IO) needle into the manubrium, following the ¼-inch rule is critical to avoid hitting the aorta.
Manual IOs are being replaced in many hospitals by other devices, such as the EZ-IO.
EZ-IO
The EZ-IO product system by Vidacare consists of a small,
battery-powered device
and 2 beveled, hollow, drill-tipped needles specifically designed to
provide safe, controlled vascular access via the IO route in patients
of all ages. The 2 separate needles have weight ranges of 3 to 39 kg
and ≥ 40 kg. The ≥ 40 kg needle was designed with a beveled drill tip
to penetrate the hard exterior of adult bones, while the 3 to 39 kg
needle is shorter in length for accessing the softer bones of pediatric
patients. (Vol III—PED12 Intraosseous Vascular Access) The tibia and
the humerus may also be used.
For the tibia, the anatomical landmarks are the same as those used for pediatric IO access, that is, just medial to the tibial tuberosity, on the flat portion of the proximal tibia. For the humerus, the anatomical landmark is the anterior humeral head. Consider local anesthesia and prophylactic antibiotic administration only if time permits. This needle can remain in place safely up to 24 hours.
Procedure for EZ-IO Insertion
Locate anatomical site and prep the skin.
Infiltrate site with local anesthetic down to level of the periosteum if needed.
Load needle into the driver. It attaches by a magnet.
Firmly stabilize the leg near (not under) the insertion site.
Firmly press the needle against the site at a 90º angle and operate the driver. Use firm, gentle pressure.
As the needle reaches the bone, stop and ensure that the 5 mm needle marking is visible. If it is, continue to operate the driver.
Power the needle into the bone until the flange touches the skin or a sudden lack of resistance is felt.
While supporting the needle set with one hand, pull straight back on the driver to detach it from the needle set.
Grasping the hub firmly with one hand, rotate the stylet counter clockwise until loose, pull it from the hub, place it in the stylet cartridge, and place in biohazard container
The manufacturer recommends not attempting to aspirate bone marrow as it may clog the needle and tubing.
If the patient responds to pain (GCS ≥8), administer preservative-free lidocaine, 50 mg IO slowly (30 sec).
If no signs of infiltration are found, attach the IV line and infuse fluids and medications as normal. (IV bag will need to be under pressure.)
Secure needle and dress the site.
EZ-IO Removal
Remove the attached EZ-connect extension set.
Attach a sterile 5 or 10 mL syringe luer lock syringe (the syringe acts as a handle).
Rotate the syringe clockwise.
While continuing to rotate the syringe, begin gently pulling the catheter out, avoiding use of excessive force.
Apply a small sterile dressing to the site.
For more information on the EZ-IO, see http://www.vidacare.com/EZ-IO/Index.aspx.
Reference
Cunningham FJ, Spivey WH. Intraosseous infusion in Clinical procedures in emergency medicine, 3rd ed. Roberts JR, Hedges JR eds. Philadelphia, WB Saunders 1988;394-401.