EZ-IO

1
EZ-IO

• By Elspeth Richardson

2
History

• Used in WWII in resusciation of haemorrhagic
  shock but then fell out of practice afterwards
• Rediscovered by paediatrician James Orlowski
  visiting India during cholera epidemic, and has
  been standard of practice in paediatric life
  support guidelines since 1980s
• Used less widely in adults, but now recommended
  in some resus guidelines as 1st alternative in
  difficult IV access in cardiac arrest setting1
• Central line out of favour in resus setting ET
  route gives lower and more variable concentrations

3
Science?

• Access through BVs in BM held open by rigid
  non-collapsible bony wall (dont collapse in
  shock) which flow into central venous system 3,4
• Quickly absorbed into systemic circulation -
  nearly identical to IV (ie. within 1 second) 5, 6
• Can deliver any blood products / fluids / drugs -
  including high volumes that cant be given via ET
• Lasts 24-48hrs

4
Why?

• The Golden Hour - potential for saving
  critically ill patients at its optimum
• Significant numbers dont receive necessary
  pre-hospital therapy due to difficult IV access1
• Access can be achieved in lt1min without serious
  complications assoc with central lines

5
When?

• APLS Recommended technique for access in
  paediatric cardiac arrest otherwise recommended
  if gt3 attempts or gt1.5mins to gain access in
  critically ill child
• Quick IV access in shock, cardiac arrest, trauma,
  combative, disaster/military medicine, mass
  casualty scenarios
• Obviously, difficult IV access
• Paediatric patients - IV access unobtainable in
  6 or more2
• Can be considered a bridge to a central line

6
How?

• Little training required, good success rate (95
  or more) in lt60secs in most cases1 (central lines
  take 11-25mins)
• Only 15 will be conscious, but those will need
  LA (average pain score on insertion without LA is
  2.5/10, or equivalent to insertion of 18-16 guage
  peripheral line ) some report significant pain
  on infusion
• Suggest initial push of 20-40mg 2 lidocaine
  (0.5mg/kg paediatric) after insertion to block
  pressure centres in IO space (not gt3mg/kg/24hrs)
  --gt then, after 15-30secs, give 10ml 0.9 saline
  flush
• Need pressure bag - flow rate alters by
  69-92ml/min

7
Sites?

• Proximal tibia - anteromedial surface, 2-3cm
  below tibial tuberosity, at 90deg to skin but
  pointing caudally to avoid growth plate
• Distal tibia
• Femoral - anterolateral surface, 3cm above
  lateral condyle

8
Sites?

• Anterolateral proximal humerus
• Sternum (not good for CPR), superior iliac crest
• Confirm placement by aspirating 5mls blood or
  flushing. Placement successful if sudden give /
  needle stands alone / fluid flows easily
• No significant difference between infusion rates
  (humeral vs tibial)1

9
Device?

• Manual device / impact driven device (bone
  injection gun - spring-loaded needle) / powered
  drill (EZ-IO - in anyone gt3kg))
• Pink - 3-39kg
• Blue - gt40kg
• Yellow - prox humerus gt40kg, or much subcutaneous
  tissue

10
Cost?

• IV line 3 - 5, although may be multiple
  attempts
• IO line 65 - 165
• CV line 200 for kit, 200 for X-ray much more
  costly if gets infected
• Less equipment, less personel, less time, quicker
  treatment, less ICU admissions, less
  complications
• According to website, EZ-IO has small
  environmental footprint!

11
Complications

• Complications are rare
• Obese - needle not long enough to reach BM space
• 0.6 rate of osteomyelitis - usually only if
  prolonged or patient bacteraemic at time of
  insertion1
• Others subcutaneous/subperiosteal infiltration
  during use, dislodgement, slow flow rate,
  fracture, compartment syndrome, skin necrosis,
  clogging of needle (frequent flushes),
  through-and-through penetration, pneumothorax /
  vascular injury / mediastinitis if sternal,
  haematoma, growth plate injuries
• Contraindicated in previous sternotomy,
  fractures above IO site, previous attempt in same
  leg/site, previous orthopaedic surgery in area of
  insertion, infection at insertion site, local
  vascular compromise, osteogenesis imperfecta,
  osteoporosis