Morning Report: 8/10/2012 - The Original Kings of County

Today we have a morning report from Dr. Auerbach with a review of intraosseous access!

IO:
Can I administer fluid rapidly? (up to 42ml/minute!)

IO vs IV?

Same time for medications to reach central circulation

Same delivery rate of fluid as central or peripheral IV when pressurized (which is preferred delivery method during resuscitation)

Indications:

Primary indication is cardiac arrest in infants

When cannot quickly establish access and need access

Contraindications:

Relative:

Osteoporosis and osteogenesis imperfect

Needle insertion through cellulitis, infection, or burns

Absolute:

Fractured bone

Recent IO placement in same bone

IO needles
-have EZ-IO

-Cook IO needle

Site:

Infants and children <6 years of age

Preferred site is proximal tibia (2 fingerwidths, (1-3cm) below the tuberosity, using the broad flat anteromedial side); this is to miss the growth plate

Other viable sites are distal tiba, and distal femur (insertion site 2-3cm above the external femoral condyle in the midline, directed cephalad at a 10-15 degree angle)

Clavicle and humerus has been used but should be last resort

In older children and adults

Preferred site is distal tibia, site of needle insertion should be medial surface at the junction of the medial malleolus and tibia shaft, posterior to the saphenous vein; insert needle cephalad

Sternum can be used as a site in adults, can be more helpful in patients with extremity injuries or amputees

Actual procedure:

Place support behind knee (i.e. towel roll)

Clean well area of insertion

Anesthesia for conscious patients, otherwise not necessary

Stabilize the extremity with free hand (however keep out of insertion plane as to avoid puncturing your hand)

Direct IO needle either perpendicular or slightly caudal

Use twisting or rotating motion until feels a decrease in resistance (penetration usually is 1CM deep into bone)

Stabilize needle

Aspiration of blood or marrow confirms correct placement

Check for extravasation of fluid outside of bone (improperly placed IO)

Obviously for EZ-IO do not need all of above

What can I send?

HGBN, Glucose, pH, PCO2, HC03, Na, Cl, BUN, creatinine, Cultures, serum drug levels. Possibly can check type and Rh too.

Complications:

Hold needle with index finger 1 CM from bevel to prevent through and through insertion

If no free flow of fluid back, either:

1) Needle not through cortex, reinsert stylet and re-advance

2) Needle through and through, pull back on it and aspirate

3) Clogged by spicule or clot: flush with saline

4) If still not working, remove and choose another site

If have extravasation, must remove needle and apply pressure and retry elsewhere

Rarer complications include infection, compartment syndrome, epiphyseal injury, fat embolism and myonecrosis

Remember: check compartments for tissue extravasation

Also, cannot leave in for more than 24 hours

Source: Roberts and Hedges, 5^th edition

Thanks Dr. Auerback! Leave any comments below.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital