E-Z IO

[Mateo_1387]

Well, let the litigation's begin. How many epiphyseal growth plates problems do I foresee?

R/r 911

I cannot find any information where an IO has caused damage to the epiphyseal growth plates in adolescents or younger. It is more likely for the person to have infection, fat emboli, and compartment syndrome versus damage to epiphyseal growth plates. The most common adverse effect seens with IO use is extravasation. It seems like a great tool when other means of vascular access are not available. My agency uses them all the time. We have not had any problems with placements that I am aware of. Our problem with them has been that some medics have put needs used to drill back in the case they came in instead of placing them in the sharps container.

[VentMedic]

Finding an ideal site for intraosseous infusion of the tibia: an anatomical study.

Clin Anat. 2003; 16(1):15-8 (ISSN: 0897-3806)

Boon JM; Gorry DL; Meiring JH

Department of Anatomy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa. jmboon@medic.up.ac.za

Intraosseous infusion is a technique used for the administration of fluids to a hemodynamically shocked child in whom attempts to access the vascular system have been unsuccessful. Although few complications are seen, injury to the epiphyseal growth plate during the performance of this technique remains a serious problem. This study investigates the relationship between the site of insertion of the intraosseous needle and the epiphyseal growth plate, and the ease of needle insertion into various locations of the tibia in newborn infants. Fourteen newborn infant cadavers (28 tibias in total) were dissected after placement of four needles: 1). through the tibial tuberosity (Site A); 2). 10 mm distal to the tibial tuberosity (Site ; 3). 20 mm distal to the tibial tuberosity (Site C) and; 4). 10 mm proximal to the tibial tuberosity (Site D). Distances from the distal end of the epiphyseal growth plate were measured. A high number of needle placements at Site A were inserted into the epiphyseal growth plate. Most placements at Site B were between 10 and 16 mm from the epiphyseal growth plate on the right side and between 10 and 15 mm on the left side, and all were inserted without difficulty. Although far from the epiphyseal growth plate, most placements at Site C were very difficult to insert because of the thick cortical bone. All placements at Site D entered the epiphysis or the epiphysis and joint space of the knee. An insertion site of at least 10 mm distal to the tibial tuberosity is therefore recommended to avoid epiphyseal growth plate injury and ensure ease of insertion.

Food and Drug Administration Update: Pediatric Highlights

Posted 04/27/2007

Marcia L. Buck, Pharm.D., FCCP; Kristi N. Hofer, Pharm.D.

In infants and children, the most commonly chosen site for IO catheter insertion is the proximal tibia. The recommended site is the flat area approximately 1 to 2 cm distal to the tibial tuberosity. It has been suggested by some authors that the needle be angled 10 to 15 degrees caudally to avoid injury to the epiphyseal growth plate. The site should be prepped with povidone iodine or a surgical scrub prior to needle insertion. In conscious patients, infiltration of the area with 1% lidocaine is recommended. Intraosseous access should not be delayed in an unconscious patient if access is needed for fluids or medications. Special large-bore (13 to 16-gauge), short-shaft IO needles, as well as auto-injectors, are available for use in older children and adults; but in infants, specifically designed neonatal IO needles should be used. If not available, an 18 or 20-gauge spinal needle may be used. The IO needle should be inserted and advanced to the periosteum, then twisted until a lack of resistance is felt. The stylet is then removed from the needle. [2,8-10]

The above paragraph is in almost every set of instructions including those by the manufacturer. You can follow the references cited in the manufacturer's instruction manual or in the PALS book for more information.

[Dr. Dick]

I am the Education Manager for a hospital based EMS service with approximately 215 employees. We started using the EZ-IO in November 2007. We have had excellent results with it. We previously used the Bone Injection Gun and have had much better efficiency with the EZ-IO. I believe your service will have good results using it.

Richard Adams

[usapride2004]

I am all for EVERY service nationwide getting the EZ-IO.

I'm with you on this one 100%. Of course... it would be nice to have Adult IO access allowed in the first place... It's a paramedic only skill right now, and there aren't a lot of Paramedics running around Rhode Island. The primary ALS provider is the EMT-Cardiac, which I like to describe as "Paramedic Light" less training, most of the scope of practice.

IO access could easily be part of the Cardiac scope of practice. I would love that.

[Dustdevil]

I'm with you on this one 100%. Of course... it would be nice to have Adult IO access allowed in the first place... It's a paramedic only skill right now, and there aren't a lot of Paramedics running around Rhode Island.

Just for clarification, when most of us here refer to EMS, we are specifically referring to paramedic level services. Anything less is not EMS. It's just an ambulance service. :wink:

[EMS2712]

Dustdevil, the more I read your posts, the more I agree with your way of thinking. We are an ALS level department. At the current time, we only have 4 EMT-Intermediates, and 99 EMT-Paramedics

[usapride2004]

Just for clarification, when most of us here refer to EMS, we are specifically referring to paramedic level services. Anything less is not EMS. It's just an ambulance service. :wink:

[AZCEP]

IO access is not the panacea that everyone is making it out to be. Yes, it is quite useful when you need vascular access, but there are several key problems with it's widespread use.

The most glaring is the inability to fluid resuscitate without a pressure infuser. An EZ-IO properly placed will not flow greater than 100 ml/hr with gravity. This does nothing to reverse the effects of hypovolemia that made IO access necessary in the first place.

Because of that problem, you have to be very careful using the site for fluid pushes. I've been witness to several syringe initiated fluid boluses following drug administration that have actually forced the IO out of the site. This was done by highly educated emergency physicians, so I don't want to hear about the lack of prehospital education on this one.

As I said, IO is a good option, but it needs to be tempered with some reality. A central vein is much better for the critical patient than an IO. The prehospital providers that are allowed to do them, and are successful should not be stripped of the privilege just to make things easier for a few that want a new skill.

[usapride2004]

Central lines are wonderful, but since you can place an IO in about 45 seconds, it's a great option for the emergency setting. That doesn't mean you can't also get the central line...

[CBEMT]

IO access could easily be part of the Cardiac scope of practice. I would love that.

Sure, why not. They're not dangerous enough as it is. In fact, they should have RSI too.

PS- your MedWreck badge is on the wrong side, isn't it?