EZ-IO Presentation 1
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Transcript of EZ-IO Presentation 1
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Advances In Intraosseous Vascular Access
Dr.med.univ. Fadel Soliman
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Presentation Agenda
• Overview (Clinical Need, IO History, Anatomy & Physiology)
• State of the Art 2006 (FDA & CE Cleared IO Devices)
• IO Research
• Specific Patient Experiences
Prospective Multi-Center Trial
Comparative Studies
• The Benefits of IO Access to Emergency Medicine
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Worldwide Clinical Need
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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6.4 Million Patients In The United StatesEmergency Medical Services
68%
17%
15%
Patients that Need IVs - 11,850,000
8,058,000Easy
Impossible1,778,000IV problems= 3,792,000 patients
Difficult2,014,000
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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6.4 Million Patients In The United StatesEmergency Department
67%10%
23%
Patients that Need IVs - 8,276,000
5,586,000Easy
Impossible828,000
Difficult1,862,000
IV problems= 2,2,000 patients
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Central Line Complications
Mechanical• Pneumothorax
• Arterial puncture with hematoma
Thrombotic• 15% of patients develop catheter related thrombus
• Causes catheter blockage
Infection
• Incidence suggests need for caution
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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History of intraosseous access IO has endured for more than 65 years as a safe and effective alternative to IV
Reports of over 4,000 adult patients treated during the 1940’s and 50’s
IO Access became a lost art for 40 years because no civilian EMS service
existed to utilize the technique
“Re-discovered” in 1985 by James Orlowski MD while on a trip to India
Established standard of care in Pediatric Advanced Life Support
Recently adopted standard of care in American Heart Association and European
Resuscitation Council guideline revisions
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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AHA and ERC Guidelines
IO should be early second line choice for vascular access following 2-3
attempts at a peripheral IV in adults and first line choice for pediatrics
The ET tube is no longer recommended for drug delivery
Central lines are discouraged
CDC report indicates 9% infection rate with central lines in US
Infections associated with 10% mortality and cost of $25k/infection
Central line placement causes unnecessary delay in drug delivery in resuscitation
setting
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Anatomy of intraosseous access
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Anatomy of intraosseous access
Thousands of small veins lead from the medullary space to the central circulation T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Anatomy of intraosseous access
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Lets Put Pain in ProspectiveLets Put Pain in Prospective
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Intraosseous access: Is it painful?
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Why Lidocaine? Anesthetic vs. Analgesic
• Pain associated with IO infusion is related to stimulation of pressure sensors (nerve fibers) in the medullary space
• Lidocaine inhibits stimulation of those sensors and the propagation of signals along the efferent pain fibers
• Pain management with analgesic agents can cause systemic effects and may not eliminate local pain
• Analgesics alter the perception of pain while anesthetics block sensation
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Right Amount of Lidocaine
Medical Director must authorize appropriate dosage rangeM-216 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Right Amount of Pressure
• The pressure in the medullary space is approximately 1/3 of the patients arterial pressure
• Pressurizing fluids for infusion is required to obtain maximum flow rates
• For aggressive fluid resuscitation a rapid infuser may increase flow rates
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Regulate fluid delivery
for ALL patients and take
patient condition into
account with amounts
delivered
Infuse fluids with pressure
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Right Flush
• The IO space is filled with a thick fibrin mesh
• The medullary space must be pressure flushed to obtain maximum flow rates
• A minimum of 10ccs is required for initial bolus
• Flush must overcome initial resistance felt with bolus administration
• More than one flush may be required to achieve maximum flow rate
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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No Flush = No FlowSyringe FLUSH catheter with 10 ml of a sterile solution
Syringe FLUSH catheter
• Prime and use extension set
• Reminder: Patients responsive to pain may require 2% preservative free Lidocaine intraosseously
• PRIOR to syringe flush
• Some patients may require multiple syringe flushes
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Pressure and Flow Rates
• With a pressure bag or infusion pump, IO flow rates are similar to IV Tibial similar to a 20 gauge catheter
Humeral similar to a 16 gauge catheter
• Flow rates for infusions given through an IO with a 300 mm pressure infuser
50 cc – 100cc/ min
Unit of blood in approximately 15 - 30 minutes
• Syringe bolus infusions can be completed in seconds
• Initial rapid 10 cc saline bolus dramatically increases IO flow rates
• With a pressure bag or infusion pump, IO flow rates are similar to IV Tibial similar to a 20 gauge catheter
Humeral similar to a 16 gauge catheter
• Flow rates for infusions given through an IO with a 300 mm pressure infuser
50 cc – 100cc/ min
Unit of blood in approximately 15 - 30 minutes
• Syringe bolus infusions can be completed in seconds
• Initial rapid 10 cc saline bolus dramatically increases IO flow rates
NO FLUSH = NO FLOWNO FLUSH = NO FLOWNO FLUSH = NO FLOWNO FLUSH = NO FLOW
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Infusion of MedicationWhich Drugs can be given?
Any medications that can be safely injected into a peripheral IV can likewise be safely injected IO
What Dose?
IO and IV doses are identical
Flow Rates (A rapid 10 cc saline bolus must be given prior to any infusion):
To maintain optimal IO flow, pressure of 300 mm Hg should be applied to the infusion bag or the pump
Lab Testing: 5 cc of blood can be aspirated from an IO device and
placed into a heparin-coated syringe for standard laboratory testing
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Right Site
Site selection is dependent upon:
• Absence of contraindications• Accessibility of the site• Ability to monitor and secure the
site• Desired flow rates
T-430 Rev, B
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
24T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Pediatric EZ-IO Insertion
• Pediatric insertion requires a gentle grip and a soft touch
• One size does not fit all - Consider tissue depth in needle selection
• Be cautious of driver recoil – release the trigger when you feel the “pop” or give
• Always use a stabilizer on newborns and infants
Caution!
Caution!
Recoil!
Recoil!
3- 39 kg usage
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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IO Indications• Cardiac arrest• Status epilepticus• Shock Trauma• Arrhythmia• Dehydration• Burns• Drug overdose• DKA (diabetic)• End stage renal disease• Stroke• Myocardial infarction
IV access is often difficult or impossible in these
situationsIO is the AnswerIO is the Answer
• Coma• Head Injury• Anaphylaxis• Congestive heart failure• Dialysis• Emphysema• Respiratory arrest• Hemophiliac crisis• Sickle Cell crisis• Pediatric shock• Chest pain
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Contraindications for EZ-IO Access
• Fracture (targeted bone)
• Previous orthopedic procedures near insertion site•Prosthetic Limb or joint
• IO within past 24 hours (targeted bone)
• Infection at the insertion site
• Inability to locate landmarks or excessive tissue
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Potential Complications for most IO devices• Extravasation
• Compartment syndrome
• Dislodgement
• Fracture
• Failure (Device or user in origin)
• Pain
• Infection
Retrospective Analysis in pediatrics and adults suggests
that infection rates are < 0.6%
Precise Insertion & Placement of the IO Device is Imperative for Success
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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FDA & CE Cleared IO Devices
• Cook/Jamshidi / Illinois Sternal
Primarily used for pediatrics
• FAST - 1
Designed for adult sternum
• B.I.G. Bone Injection Gun
Projects a needle set into adult tibia
• EZ-IO
Powers a hollow needle set into the medullary space
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Manually InsertedManually Inserted
Manually inserted hand held infusion needles have been
available for years
Mostly used for infants because
their bones are soft
COOK
JAMSHIDIJAMSHIDI
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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FAST-1 (PYNG)
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Bone Injection Gun (BIG)™The Bone Injection Gun (BIG)™
Adult B.I.G - 15GPediatric B.I.G - 18G
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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A New Intraosseous DeviceA New Intraosseous Device
Approved for adult and pediatric use
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The Right NeedleSelection based on:• Weight Range (PD 3-39kg , AD ≥40kg or LD excessive tissue)• Soft tissue depth judged by calibrating your finger• Visualization of the 5mm mark after penetration of the skin• Special situations for use of the LD needle
Excessive soft tissue
Excessive muscle tissue
Edema
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
40Length and color are the only differences between Needle Sets
EZ-IO AD 25 mm Needle Set
EZ-IO LD 45 mm Needle Set
5 mm mark
EZ-IO PD 15 mm Needle Set
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
41in approved bio-hazard sharps containers
Portable sharps protector
EZ-IO LD sharps protector
Put Stylets Where They Belong . . .
T-430 Rev, B
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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How IO Benefits Patients and Providers• Saves time
• Saves lives
• Decreases risk of complications
• Saves Money
• Improves Clinical Excellence
• Easy to use (Intuitive)
• Easy to maintain (competency and equipment)
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Study Objective:
To compare - IO bolus vs IV bolus for vascular delivery of drugs during experimental CPR
Subjects: Ten swine (25–30 kg), anesthetized, instrumented & subjected to cardiac arrest and CPR.
IO drug delivery during CPR Kramer C. et al
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Protocol
No treatment: 8 minutes
CPR: 2 minutes
INJECT
BolusEvans Blue/Epinephrine
0.2 mg/ml
BolusICG/Epinephrine
0.2 mg/ml
Tibia Series -1
IV Series -2
Sternum
Cardiac ArrestKCI
Cardiac ArrestKCI
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Appearance time
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Peak Concentrations
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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How effective is IO during CPR?
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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EZ-IO RemovalMaintain a 90 degree angle
Rotate the syringe clockwise
Gently pull
Maintain 90 degree angle, Rotate clockwise and gently Pull
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The reality of intraosseous access
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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The 5 Rights of the EZ-IO
1. The Right Needle
2. The Right Site
3. The Right Amount of Lidocaine
4. The Right Flush
5. The Right Amount of Pressure
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
53DO NOT SUBMERGE DRIVER AT ANY TIME
Cleaning & Disinfecting
• Wipe clean with moistened cloth
• Spray with anti-microbial solution
• Momentarily depress trigger several times during cleaning
• Clean around drive shaft with cotton applicator – check to ensure nothing has attached to the magnetic tip
• Wipe dry
• Inspect driver and return to case or replace trigger guard
T430 RevA
10.01.2007 Copyright Vidacare 2007 Fadel Soliman, Dr.med.univ.
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Questions