Seizing and No Access!!!

The intraosseous route and device was first discovered and developed in 1922, and became popular during World War II for resuscitating combat victims. However popularity soon died off with the advent of steel needles and plastic peripheral cannulas. A resurgence was seen between 1980 and 2000 in paediatric patients that had difficult vascular access and needed rapid access for resuscitation purposes. However, since the middle of the last decade intraosseous use has really taken off, and it is now widely used and accepted in adult patients, particularly in emergent situations but also in some non-emergent situations.

The devices have dramatically changed over the years. The early days saw the use of the modified manual Dickmann Needle and the Jamshidi Needle, and now we have equipment like the Bone Injection Gun and the popular power-driven EZ-IO.

The bone marrow space allows for a non-collapsible vein to be created, and allows rapid access to central circulation.

The EZ-IO is one of the most popular devices currently in use in emergency departments and is the device the LITFL team are most familiar with. The EZ-IO can insert a catheter into the intraosseous space within 10 seconds, has a 92-97% first pass success rate, and can manage 5-9 liters of fluid per hour through a single catheter hub.

Intraosseous access should be considered in patients who:

• are critically ill and peripherally shut-down
• have an immediate need for drugs and fluids
• previously required central venous access for infusion due to difficult vascular access
• have limited or no vascular access
• require multiple IV sticks to obtain vascular access for medication or fluid infusion
• immediate pain management
• need immediate fluid resuscitation
• are in cardiac or respiratory arrest
• require rapid intubation or sedation
• are experiencing a psychiatric emergency
• are involved in pre-hospital, disaster and mass casualty situations

• Quicker (seconds rather than minutes)
• Easier
• Cheaper ($100 vs $300)
• Multiple insertion sites are avaialble
• Less training and experience required
• Less complications and catheter related blood stream infections
• Less pain and discomfort during insertion
• the same drugs may be administered
• blood samples can be obtained for laboratory analysis

“Delivery of drugs via an endotracheal tube is no longer recommended – if IV access cannot be achieved, drugs should be given by the IO route”
— ILCOR 2010

The main disadvantage of intraosseous access is that haemodynamic monitoring is not possible.

Any medication/fluid you infuse through an IV/CVC can go be administered IO.

Some exaples are provided in these case reports:

• Fibrinolysis in STEMI [pubmed]
• Resuscitation in massive obstetric hemorrhage [pubmed]
• Iodinated CT contrast agents [pubmed]
• Blood products and epinephrine in hemorrhagic shock [pubmed]

Currently recommended sites (from the manufacturer) for the EZ-IO are the:

1. Proximal humerus – (Palpate the anterior mid-shaft humerus, and continue palpating proximally up the anterior surface of the humerus until the greater tubercle is met. Palpate the coracoid and acromion, then imagine a line between them. The insertion point is about 2cm from its midpoint).
2. Proximal tibial – (In adults, two fingers’ breadths below and medial to the tibial tuberosity)
3. Distal tibia – (In adults, two fingers’ breadths proximal to the tip pf the medial malleolus)

However any bone with an intraosseous space can be used to place an intraosseous catheter. Current literature and studies seem to favour the proximal humerus as the preferred site, as it is close to the heart and allows the quickest absorption of fluids/medications into the central circulation.

Image From: www.regval.com

Selecting catheter size is similar to an IV with different sizes, for different ages and bone size:

• Pink — paediatric patients 3-39kg
• Blue — Patients >39kg
• Yellow — for patients with extensive soft tissues of insertion site.

Image used with permission from: www.regval.com

The intraosseous catheter is contra-indicated in the following situations:

• Previous IO attempts in the same bone
• Previous surgery at the same site (knee replacement, etc.)
• Osteogenesis imperfecta
• Osteoporosis
• Infection of the tissue overlying the insertion site
• Difficulty or inability to locate landmarks

Complications are rare, however the following have been reported:

• Osteomyelitis
• Extravasation
• Subcutaneous abscess
• Leakage around insertion site
• Difficulty removing device

Medications administered through the IO are pharmacokinetically equivalent in blood serum concentrations to those administered via the IV route.

The following videos demonstrate how quickly fluids/medication are absorbed once injected into the intraosseous space.

First, the proximal humerus:

And now, the proximal tibia:

• Once an IO catheter is inserted, aspirate bone marrow to ensure your in correct space. You can even use this aspirate for pathology testing, then flush the catheter with a 20ml flush to ensure it is patent.
• Flow rates can sometimes be slower related to the anatomy of the intraosseous space and catheter patency, if initially slow repeat 20 ml flush. Application of pressure bags over the fluids can increase flow or use pump/syringe drivers for continuous infusions.
• Securing and protection of the intraosseous catheter can be difficult, but generally device stays in situ by itself  without problems.
• Insertion and continuous infusion can caused some localised pain for conscious patients insertion of 2% lignocaine and repeated at regular intervals can minimise this.
• The EZ-IO catheter can only stay in situ for up to 24 hours (manufacturer’s recommendation). The site should be monitored frequently for signs of erythema, swelling or evidence of extravasation. If these are noted, then remove the device immediately.
• Removing the EZ-IO catheter involves disconnecting infusions, attaching a 10 ml luer-lock syringe to the catheter hub, then rotate the catheter clockwise-while pulling straight back, disposing of catheter in bio-hazard container, and apply simple dressing.