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  • Volume I:
    First Thirty Minutes
    • Section 1
      Acute Care Algorithm/ Treatment Plans/ Acronyms
      • CALS Approach
        • CALS Universal Approach
        • Patient Transport
      • Airway
        • Rapid Sequence Intubation Algorithm/Rescue Airways
        • Endotracheal Intubation FlowSheet
        • Rapid Sequence Intubation Medications
        • Rapid Sequence Intubation Drug Calculator
        • Rapid Sequence Intubation Dosage Chart
        • Obstructed Airway Algorithm Adult and Pediatric
        • Initial Laboratory Studies
      • Cardiovascular
        • CPR Steps for Adults, Children, and Infants
        • Automated External Defibrillator Algorithm
        • Ventricular Fibrillation-Pulseless Ventricular Tachycardia Algorithm
        • Pulseless Electrical Activity Algorithm-Adult and Peds
        • Asystole Algorithm-Adult and Peds
        • Bradycardia Algorithm
        • Tachycardia Algorithm
        • Atrial Fibrillation/Atrial Flutter Algorithm
        • Electrical Cardioversion Algorithm-Adult and Pediatric
        • Chest Pain Evaluation Algorithm
      • Emergency Preparedness
        • Therapeutic Hypothermia
        • Mobilization Checklist
        • Symptom Recognition-Therapy
        • Blast Injuries
      • Fluids & Electrolytes
        • Causes of Anion and Non-Anion Gap Acidosis
      • Infection
        • Sepsis Guidelines
      • Neonatal
        • Neonatal Resuscitation Algorithm
        • Inverted Triangle-APGAR Score
        • Drugs in Neonatal Resuscitation Algorithm
      • Neurology
        • Altered Level of Consciousness
        • Glasgow Coma Scale-Adult, Peds,Infant
        • Tips From the Vowels Acronym
        • NIH Stroke Scale (Abbreviated)
        • Status Epilepticus Treatment Plan
      • Obstetrics
        • Postpartum Hemorrhage Algorithm
        • Shoulder Dystocia—HELPERR
        • Vacuum Delivery Acronym-ABCDEFGHIJ
      • Ophthalmology
        • Central Retinal Artery Occlusion
        • Chemical Burn Exposure to Eye
      • Pediatrics
        • Pediatric Equipment Sizes
        • Modified Lund Browder Chart
      • Trauma
        • Shock Acronym-Shrimpcan
        • Burn Management Treatment Plan
        • Initial Care of Major Trauma
        • Trauma Flow Sheet
    • Section 2
      Universal Approach
      • CALS Universal Approach To Emergency Advanced Life Support
    • Section 3
      Steps 1-6
      • Steps 1-6
      • Step 1: Activate the Team
      • Step 2: Immediate Control and Immobilization
      • Step 3: Initial Survey
      • Step 3: Simultaneous Team Action By Team Members
      • Step 4: Preliminary Clinical Impression
      • Step 5: Working Diagnosis and Disposition
      • Step 6: Team Process and Review
    • Section 4
      Preliminary Impression/Focused Clinical Pathways
      • Pathway 1: Altered Level of Consciousness (Adult and Pediatric)
      • Pathway 2: Cardiovascular Emergencies (Adult and Pediatric)
      • Pathway 3: Gastrointestinal/Abdominal Emergencies (Adult and Pediatric)
      • Pathway 4: Neonatal Emergencies
      • Pathway 5: Obstetrical Emergencies
      • Pathway 6: Adult Respiratory
      • Pathway 7: Pediatric Respiratory
      • Pathway 8: Adult Trauma (Secondary Survey for Adults)
      • Pathway 9: Pediatric Trauma (Secondary Survey for Trauma in Children)
  • Volume II:
    Resuscitation Procedures
    • Section 5
      Airway Skills
      • Airway Skills 1: Aids to Intubation
      • Airway Skills 2: Bag-Valve-Mask Use
      • Airway Skills 3: Orotracheal Intubation
      • Airway Skills 4: Rapid Sequence Intubation
      • Airway Skills 5: Cricoid Pressure and the BURP Technique
      • Airway Skills 6: Esophageal Tracheal Combitube
      • Airway Skills 7: King Airway
      • Airway Skills 8: Intubating Laryngeal Mask Airway
      • Airway Skills 9: Nasotracheal Intubation
      • Airway Skills 10: Topical Anesthesia
      • Airway Skills 11: Retrograde Intubation
      • Airway Skills 12: Tracheal Foreign Body Removal
      • Airway Skills 13: Cricothyrotomy
      • Airway Skills 14: Tracheotomy
      • Airway Skills 15: Tracheotomy in Infants
      • Airway Skills 16: Transtracheal Needle Ventilation
    • Section 6
      Breathing Skills
      • Section 6 Breathing Skills Portals
      • Breathing Skills 1: Chest Tube Insertion
      • Breathing Skills 2: Chest Suction and Autotransfusion
      • Breathing Skills 3: Endobronchial Tube
      • Breathing Skills 4: Heliox
      • Breathing Skills 5: Needle Thoracostomy
    • Section 7
      Circulation Skills
      • Section 7 Circulation Skills Portals
      • Circulation Skills 1: Arterial and Venous Catheter Insertion
      • Circulation Skills 2: Central Venous Access
      • Circulation Skills 3: Central Venous Pressure Measurement
      • Circulation Skills 4: Emergency Thoracotomy
      • Circulation Skills 5: Intraosseous Needle Placement (Adult)
      • Circulation Skills 6: Pericardiocentesis
      • Circulation Skills 7: Rewarming Techniques
      • Circulation Skills 8: Saphenous Vein Cutdown
      • Circulation Skills 9: Transvenous Cardiac Pacing
    • Section 8
      Disability Skills
      • Section 8 Disability Skills Portals
      • Disability Skills 1: Skull Trephination
      • Disability Skills 2: Raney Scalp Clips
    • Section 9
      Trauma Skills
      • Trauma Skills Portals
      • Trauma Skills 1: Compartment Pressure Measurement
      • Trauma Skills 2: Femur Fracture Splinting
      • Trauma Skills 3: Pelvic Fracture Stabilization
      • Trauma Skills 4: Suprapubic Cystostomy
    • Section 10
      X-Rays Skills
      • X-ray Skills 1: Cervical Spine Rules and Use of Imaging Portal
      • X-ray Skills 2: Cervical Spine X-ray Interpretation
      • Xray Skills 3: Interpretation of a Pelvic X-ray
  • Volume III:
    Definitive Care
    • Section 11
      Airway
      • Rapid Sequence Intubation Portal
      • Airway Obstruction Portal
      • Heliox Treatment Portal
      • Ventilator Management Portal
      • Noninvasive Ventilatory Support Portal
      • Inspiratory Impedance Threshold Device Portal
      • Status Asthmaticus Portal
      • Anaphylaxis Portal
    • Section 12
      Cardiovascular
      • Cardiovascular 1: Classification of Pharmacological (Therapeutic) Interventions Portal
      • Cardiovascular 2: Cardiac Rhythms Portal
      • Cardiovascular 3: Pharmacology of Cardiovascular Agents Portal
      • Cardiovascular 4: Endotracheal Drug Delivery
      • Cardiovascular 5: Ventricular Fibrillation/Pulseless Ventricular Tachycardia Portal
      • Cardiovascular 6: Pulseless Electrical Activity Portal
      • Cardiovascular 7: Asystole Treatment Portal
      • Cardiovascular 8: Tachycardia Treatment Portal
      • Cardiovascular 9: Electrical Cardioversion Portal
      • Cardiovascular 10: Bradycardia Treatment Portal
      • Cardiovascular 11: Acute Coronary Syndromes Portal (Acure Ischemic Chest Pain)
      • Cardiovascular 12: Acute Heart Failure Portal
      • Cardiovascular 13: Hypertensive Crises Portal
      • Cardiovascular 14: Digitalis Toxicity Portal
      • Cardiovascular 15: Long QT Syndrome Portal
      • Cardiovascular Diagnostic Treatment Portals
    • Section 13
      Emergency Preparedness
      • Emergency Preparedness 1: Community-Wide Collaboration Portal
      • Emergency Preparedness 2: Approaches to Planning
      • Emergency Preparedness 3: Hazard Vulnerability Analysis Portal
      • Emergency Preparedness 4: Incident Command System Portal
      • Emergency Preparedness 5: Emergency Management Program Portal
      • Emergency Preparedness 6: Basic All Hazards Response Portal
      • Emergency Preparedness 7: Rapid and Efficient Mobilization Portal
      • Emergency Preparedness 8: Emergency Event Response Classifications Portal
      • Emergency Preparedness 9: Triage Portal
      • Emergency Preparedness 10: Surge Capacity Planning and Scarce Resources Guidelines
      • Emergency Preparedness 11: Glossary of Terms
      • Emergency Preparedness 12: Resources
      • Emergency Preparedness 13: Introduction to Nuclear, Biological, and Chemical Warfare
      • Emergency Preparedness 14: Nuclear Devices Portal
      • Emergency Preparedness 15: Acute Radiation Syndrome Portal
      • Emergency Preparedness 16: Biological Agents Portal
      • Emergency Preparedness 17: Chemical Agents Portal
      • Emergency Preparedness 18: Explosion and Blast Injuries Portal
      • Emergency Preparedness 19: Patient Isolation Precautions
      • Emergency Preparedness 20: Additional References and Resources
    • Section 14
      Endocrine and Metabolic
      • Endocrine and Metabolic 1: Adrenal Crisis Portal
      • Endocrine and Metabolic 2: Diabetic Ketoacidosis Portal
      • Endocrine and Metabolic 3: Myxedma Coma (Severe Hypothyroidism) Portal
      • Endocrine and Metabolic 4: Thyroid Storm Portal (Severe Thyrotoxicosis/Hyperthyroidism)
      • Endocrine and Metabolic 5: Hyperosmolar (Hyperglycemic) Non-Ketotic State Portal
      • Endocrine and Metabolic 6: Acid-Base Portal Concepts and Clinical Considerations
      • Endocrine and Metabolic 7: Disorders of Electrolyte Concentration Portal
    • Section 15
      Environmental
      • Environmental 1: Hypothermia Portal
      • Environmental 2: Hyperthermia/Heat Stroke Portal
      • Environmental 3: Burns Management Portal
      • Environmental 4: Near Drowning Portal
      • Environmental 5: High Altitude Illness Portal
      • Environmental 6: Snake Bite Portal
    • Section 16
      Farming
      • Farming 1: Respiratory Illnesses Portal
      • Farming 2: Farm Wounds/Amputation Portal
      • Farming 3: Chemical Exposures Portal
    • Section 17
      Gastrointestinal/
      Abdominal
      • Gastrointestinal/Abdominal 1: Esophageal Varices Portal
    • Section 18
      Geriatrics
      • Geriatrics 1: General Aging Portal
    • Section 19
      Infection
      • Infection 1: Adult Pneumonia
      • Infection 2: Meningitis Portal
      • Infection 3: Sepsis in Adults Portal
      • Infection 4: Abdominal Sepsis Portal
      • Infection 5: Tetanus Immunization Status Portal
    • Section 20
      Neonatal
      • Neonatal 1: Neonatal Resuscitation Algorithm
      • Neonatal 2: Drugs in Neonatal Resuscitation
      • Neonatal 3: Meconium Suctioning Portal
      • Neonatal 4: Umbilical Artery and Vein Cannulation Portal
      • Neonatal 5: Inverted Triangle/Apgar Score Portal
      • Neonatal 6: Meningitis/Sepsis in Newborn Portal
      • Neonatal 7: Respiratory Distress Syndrome Scoring System Portal
    • Section 21
      Neurology
      • Neurology 1: Status Epilepticus Portal
      • Neurology 2: Stroke Portal
      • Neurology 3: NIH Stroke Scale Portal
      • Neurology 4: Phenytoin and Fosphenytoin Loading Portal
      • Neurology 5: Increased Intracranial Pressure Portal
    • Section 22
      Obstetrics
      • Obstetrics 1: Physiology of Pregnancy Portal
      • Obstetrics 2: Ultrasound Use Portal
      • Obstetrics 3: Bleeding in Early Pregnancy/Miscarriage Portal
      • Obstetrics 4: Dilatation and Curettage Portal
      • Obstetrics 5: Fetal Heart Tone Monitoring Portal
      • Obstetrics 6: Preterm Labor Management Portal
      • Obstetrics 7: Bleeding in the Second Half of Pregnancy Portal
      • Obstetrics 8: Hypertension In Pregnancy Portal
      • Obstetrics 9: Trauma in Pregnancy Portal
      • Obstetrics 10: Emergency Cesarean Section Portal
      • Obstetrics 11: Imminent Delivery Portal
      • Obstetrics 12: Malpresentations and Malpositions: Breech, Occiput Posterior Portal
      • Obstetrics 13: Assisted Delivery Portal
      • Obstetrics 14: Shoulder Dystocia Portal
      • Obstetrics 15: Third-stage and Postpartum Emergencies Portal
      • Obstetrics 16: Thromboembolic Disease and Pregnancy Portal
    • Section 23
      Pediatrics
      • Pediatrics 1: Physiologic and Anatomic Considerations Portal
      • Pediatrics 2: Tracheal Foreign Body Portal
      • Pediatrics 3: Epiglottitis Portal
      • Pediatrics 4: Laryngotracheal Bronchitis (Croup) Portal
      • Pediatrics 5: Bacterial Tracheitis Portal
      • Pediatrics 6: Bronchiolitis Portal
      • Pediatrics 7: Pneumonia Portal
      • Pediatrics 8: Sepsis Portal
      • Pediatrics 9: Meningitis Portal
      • Pediatrics 10: Diphtheria Portal
      • Pediatrics 11: Glasgow Coma Scale Portal
      • Pediatrics 12: Intraosseous Vascular Access
    • Section 24
      Sedation/
      Pain Control/
      Anesthesia
      • Sedation/Pain Control/Anesthesia 1: Procedural Sedation
      • Sedation/Pain Control/Anesthesia 2: Management of Combative, Agitated, Delirious Patients
      • Sedation/Pain Control/Anesthesia 3: Malignant Hyperthermia Portal
    • Section 25
      Toxicology
      • Toxicology 1: Systematic Approach
      • Toxicology 2: Essential Antidotes Portal
      • Toxicology 3: Acetaminophen Overdose Portal
      • Toxicology 4: Aspirin Overdose Portal
      • Toxicology 5: Tricyclic Antidepressants Overdose Portal
      • Toxicology 6: Beta Blocker Toxicity Portal
      • Toxicology 7: Calcium Channel Blocker Toxicity Portal
      • Toxicology 8: Bendodiazepine Overdose Portal
      • Toxicology 9: Alcohol Withdrawal Portal
      • Toxicology 10: Toxic Alcohols: Methanol and Ethylene Glycol
      • Toxicology 11: Cocaine Ingestion Portal
      • Toxicology 12: Narcotic Overdose Portal
      • Toxicology 13: Amphetamine Analog Intoxication Portal
      • Toxicology 14: Iron Ingestion Portal
      • Toxicology 15: Carbon Monoxide Poisoning Portal
      • Toxicology 16: Hyperbaric Oxygen and Normobaric Oxygen
      • Toxicology 17: Cyanide Poisoning Portal
      • Toxicology 18: Organophosphates Toxicity Portal
    • Section 26
      Trauma Care
      • Trauma Care 1: Shock Portal
      • Trauma Care 2: Shock Evaluation Overview Portal
      • Trauma Care 3: Use of Hemostatic Agents to Control Major Bleeding Portal
      • Trauma Care 4: Severe Traumatic Brain Injury—Adult 
      • Trauma Care 5: Severe Traumatic Brain Injury—Pediatric
      • Trauma Care 6: Compartment Syndrome
    • Section 27
      Tropical Medicine
      • Tropical Medicine 2: Introduction
      • Tropical Medicine 3: Fever and Systemic Manifestations
      • Tropical Medicine 4: Gastrointestinal and Abdominal Manifestations
      • Tropical Medicine 5: Dermatological Manifestations
      • Tropical Medicine 6: Muscular Manifestations (Including Myocardium)
      • Tropical Medicine 7: Neurological Manifestations
      • Tropical Medicine 8: Ocular Manifestations
      • Tropical Medicine 9: Pulmonary Manifestations
      • Tropical Medicine 10: Urogenital Manifestations
      • Tropical Medicine 11: Disorders of Nutrition and Hydration
      • Tropical Medicine 12: Medicine in Austere Environs
      • Tropical Medicine 13: Antiparasitic Primer
      • Tropical Medicine 14: Concise Parasitic Identification
      • Tropical Medicine 15: Bibliography
    • Section 28
      Ultrasound
      • Ultrasound 1: Emergency Ultrasound Applications Portal
      • Ultrasound 2: Emergency Ultrasound Techniques Portal

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Pediatrics 12: Intraosseous Vascular Access

PEDS: Because this entire portal pertains only to pediatric patients, the convention of underlining has been omitted.

The establishment of an intravenous line in an injured or critically ill infant or young child may be very difficult or impossible. This may delay the administration of critically needed fluids or medications. The intraosseous approach is a useful technique of gaining vascular access within a couple of minutes or fewer and may be lifesaving.
Intraosseous infusion is the establishment of an intravenous infusion into the bone. Long bones contain cavities called medullary or marrow cavities, which are a spongy network of venous sinusoids that drain into a central venous canal.

These central venous canals drain via emissary veins into the general circulation.1 Fluids and medications injected into these marrow cavities are rapidly picked up by these blood vessels and carried into the central circulation. The intraosseous acts as a non-collapsible vein and permits access into the central circulation as rapidly as any peripheral vein. These veins will not even collapse during shock.2

Any site that contains marrow is a potential site for intraosseous infusions. Sites include the distal femur greater trochanter, anterior tibial plateau, sternum, medial and lateral malleoli, os calcis, and the anterior superior iliac spine.2 The intraosseous is not meant to be used as a definitive method of intravenous access and should not be used for more than 12 hours.

Indications for the Use of the Intraosseous Infusion
The intraosseous is considered for use when a patient needs medications or volume expansion and an IV is unable to be started on a timely basis. Also, it is risky or not possible to start a central line by subclavian or internal jugular technique, and the endotracheal route will not allow the delivery of the medications or fluids.

Clinical indications to consider placing an intraosseous in children include:

  • Shock with vascular collapse
  • Cardiac arrest
  • Severe dehydration
  • Status epilepticus
  • Massive trauma or major burns
  • Edema or obesity in small children
  • Loss of normal veins due to previous intravenous therapy
  • Intravenous drug abuse

In such cases, time is crucial. If a peripheral line cannot be started in 2 attempts or in fewer than 90 seconds, clinicians should consider starting an intraosseous line.3

Site Selection for Intraosseous Insertion
In children younger than 6 years, the sites most readily available and preferred for use4,5 are (1) the proximal flat-broad tibial plateau, 1 to 2 finger breadths (1 to 2 cm) below the tibial tubercle on the anteromedial surface and (2) the distal femur, 2 to 3 cm above the external condyles in the midline. The bone cortex is easily penetrated in patients up to 6-years-old. After 6 years of age, the cortex becomes progressively thicker and harder to penetrate. In older children the medial distal tibia, 1 to 2 finger breaths proximal to the medial malleolus and sufficiently posterior to avoid the saphenous vein, may be used.1,5 Be sure to avoid the epiphyseal plates of the distal femur or the proximal and distal tibia.2 (Figure 1) Other indications to avoid in the use of the intraosseous needle include recent fracture to the extremity, infected burns or cellulitis, osterogenesis imperfecta, and osteopetroses.2

13-ped_12_A

Insertion of the Intraosseous Needle
The easiest method of intraosseous access is the EZ-IO. If this is not available, use an intraosseous needle with a stabilizing guard, such as the 16-gauge Illinois Sternal Iliac Aspiration Needle made by Sherwood Medical (both pediatric and adult).

13_ped_12_B

A smaller size such as the 18-gauge Jamshidi needle (made by Dyna Med) is available for neonates and infants.

13_ped_12_C

Insertion of the Intraosseous Needle into the Proximal Tibia

  1. Identify the site for puncture. The flat anteromedial surface of the tibia one- to two-finger breadths below the level of the tibial tuberosity is the preferred site.
  2. Position the leg with the knee slightly bent and semi-externally rotated. Place a sandbag or towel roll under the leg for support.
  3. Prepare the site with povidine solution.
  4. Place the hub of the intraosseous needle handle in the palm of your hand and place your index finger on the shaft. Insert it firmly through the skin onto the tibia. When the needle is resting against the tibia, turn down the needle guard until it is approximately 1/4 inch from the skin.

The needle guard is placed so that the needle does not penetrate too far. The alignment of the needle, wrist, and elbow in a straight line gives the operator better control of the needle while increasing strength.  (Figure 4)

13_ped_12_D
  1. Hold the leg with your non-dominant hand behind the leg at the level of puncture. Raise your elbow so that the needle held in the palm of your dominant hand forms a straight line with your wrist and elbow. The needle should be at right angles to the skin. Placing your arm in this position allows you to turn the needle as you push it into the bone without wobbling and sliding off of the bone.

  2. Push and turn the needle with a twisting type motion until the guard rests against the skin. You will usually feel a give as the needle enters the marrow cavity.

  3. Indications of successful intraosseous insertion include2,3:
    • An obvious pop or give as the needle enters the marrow cavity.
    • An obvious pop or give as the needle enters the marrow cavity.
    • The needle will feel firmly fixed by the bone and stand upright without support.
    • Remove the needle trocar and check for placement by injecting 1/2 to 1 mL of saline solution then aspirate. A bloody "flashback” indicates that the marrow cavity has been entered. Marrow may not always be aspirated.
    • Use 5 to 10 cc of NS to flush the needle and observe for extravasation and confirm placement. The fluid should flush easily.

  4. Fasten a T-connector with stopcock attached into the IO needle. Attach this to the IV tubing. (Figure 5) Attach the IV tubing as quickly as possible to prevent clotting. If for some reason the administration set cannot be connected, immediately replace the stylet until the tubing is ready. If the needle site cannot be confirmed, remove the needle and try another site. The proximal tibia and distal femur sites of both legs are acceptable to use.

  5. Blood samples taken from the intraosseous can be used to measure electrolytes, blood cultures, blood gases, type and cross, and hemoglobin. However, these lab tests are not the primary reason for this procedure; access is.2,7
13_ped_12_E
  1. After insertion of the intraosseous needle, secure the needle by using a piece of twill tape. Cut a piece of twill tape long enough to wrap around the leg and also to secure the knot. Form a loop at the middle of the twill tape. Pass the loop around the IO needle and pull the tape through it to form a Lark’s Head Hitch. Assure that the hitch will not slip by tying a single overhand knot around it. Pass one limb of the tape around the patient’s leg using a Magill forceps to pull it around with minimal movement then tie the two ends together. For an illustration of the Lark’s Head Hitch, see Vol II—AIR SKILLS 1, Aids to Intubation, Securing an ET Tube. If this is the only established IV site, guard it carefully until another site can be established.

Insertion of the Intraosseous Needle into the Distal Medial Tibia (Figure 6):

  1. Identify the puncture site one- to two-finger breadths proximal to the medial malleolus, sufficiently posterior to avoid the saphenous vein.
  2. Externally rotate the leg.
  3. Use only as last choice in young children.

13_ped_12_F

  1. Prepare the skin with povidine.
  2. Hold the needle with stylet (trocar) in place at a right angle to the bone.
  3. Proceed with insertion, confirmation of proper placement, connection of the IV, and securing of the intraosseous needle as above.

Removal
If the needle is removed, hold pressure on the site for 5 minutes and cover with a sterile dressing. Do not attempt to reuse the site as this will cause leakage of fluids into the surrounding tissue.

Substances That can be Infused Via Intraosseous Route

  • Crystalloids, colloids, blood, and blood products,
  • Medications such as calcium, glucose, atropine, sodium bicarbonate, epinephrine, diazepam, dopamine/dobutamine, and anesthetic agents.

Rate of Absorption of Medications and Fluids
The rate of absorption of meds given by IO appears to equal the rate given by peripheral IV. Medications given IO take 15 seconds or less to reach the central circulation. Flushing the IO line with 20 cc of NS after the medication is given facilitates the rate at which medications reach the central circulation. (Be careful not to cause fluid overload.)

Complications of the IO
Although complications are seldom, they may include the following:

  • Osteomyelitis
  • Periostitis
  • Subcutaneous edema due to leakage
  • Fat embolus
  • Subcutaneous abscess
  • Growth plate injury
  • Leakage out of another hole in the bone
  • Bone marrow damage
  • Skin infection

Formation of small, indurated areas at the injection site is commonly observed. These are the result of fluid escaping from the marrow cavity around the needle during the injection and accumulating in the soft tissue. These should resolve by themselves and cause no problems.

Infusion Techniques
Flow through the intraosseous infusion line will usually be slow. Using a syringe with a three-way stopcock or a pressure bag can enhance the rate of infusion. Inflate the pressure bag to 300 torr. Some infusion pumps may alarm when attached to an intraosseous needle due to the pressure settings of the pump. Use of a syringe and three-way stopcock attached to the IV line is an effective method to administer fluid. Attach a 30 or 60 cc syringe to the three-way stopcock. (Figure 7)

13_ped_12_G

Close the stopcock to the patient, and open the valve from the IV bag to the syringe. Withdraw the plunger to fill the syringe with the desired amount of IV fluid from the IV bag. Close the flow to the IV bag and open the valve allowing fluid to flow from the syringe to the patient. Inject the desired amount of fluid or medication to the patient. Repeat as necessary.


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 3 needles specifically designed to provide safe, controlled vascular access via the IO route in patients of all ages. The EZ-IO needle sets are 15 mm (3 to 39 kg), 25 mm (≥ 40 kg), and 45 mm (excessive tissue). 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. The excessive tissue needle was designed for overweight/obese patients. Note that the size of the needle used has more to do with body fat than weight.
The most common site for IO insertion is the proximal tibia. Alternative sites are the distal femur, distal tibia, and humerus. 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. The distal femur is the second choice in pediatric patients. Landmarks in the distal femur are harder to locate because overlying tissues are thicker.

To insert in the distal femur, slightly flex and externally rotate the hip, and flex the knee so that the quadriceps are relaxed. Insert the needle in the anterior midline, above the external epicondyles, 1-3 cm above the femoral plateau.

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.

EZ-IO    

Procedure for EZ-IO Insertion

  1. Locate anatomical site and prep the skin.
  2. Infiltrate site with local anesthetic down to level of the periosteum if needed.
  3. Load needle into the driver. It attaches by a magnet.
  4. Firmly stabilize the leg near (not under) the insertion site.
  5. Firmly press the needle against the site at a 90-degree angle and operate the driver. Use firm, gentle pressure.
  6. 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.
  7. Power the needle into the bone until the flange touches the skin or a sudden lack of resistance is felt.
  8. While supporting the needle set with one hand, pull straight back on the driver to detach it from the needle set.
  9. 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
  10. The manufacturer recommends not attempting to aspirate bone marrow as it may clog the needle and tubing.
  11. If the patient responds to pain (GCS ≥8), administer preservative-free Lidocaine, 0.5 mg/kg up to a maximum of 50 mg slowly (30 sec).
  12. 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.)
  13. Secure needle and dress the site.

EZ-IO Removal

  1. Remove the attached EZ-connect extension set.
  2. Attach a sterile 5 or 10 mL syringe luer lock syringe. (The syringe acts as a handle.)
  3. Rotate the syringe clockwise.
  4. While continuing to rotate the syringe, begin gently pulling the catheter out, avoiding use of excessive force.
  5. Apply a small sterile dressing to the site.

(See www.vidacare.com.)

References

  1. McHugh MJ. IO infusions in children. Emergency. January 1990:21-23.
  2. Friery J et al. Start an IV in that bone. Emergency. November 1987:28-33.
  3. Stenzel JP. Intraosseous venous access: teaching a new dog old tricks. Ramsey Critical Care Bulletin. June 1989.
  4. Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med. 1985;14(9)885-888.
  5. Brillman JC. Intraosseous infusion for emergency intravascular access. Top Emergency Med. 1988;10:75-80.
  6. Waisman M, Waisman, D. Bone marrow infusion in adults. J Trauma. 1997;42:288-293.
  7. Dubick MA, Holcomb JB. A review of intraosseous vascular access: current status and military application. Mil Med. 2000;165(7):552-559.
  8. Calkins MD, Fitzgerald G, Bentley TB, Burris D. Intraosseous infusion devices: a comparison for potential use in special operations. J Trauma. 2000;48:1068-1074.
Edition 13-October 2011 revised 20120330

Copyright©CALS. Comprehensive Advanced Life Support | © 2012 CALS Program