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Distal TibialTraining Program

Distal TibialTraining Program

The Vidacare EZ-IO AD Distal Tibia Training Program is designed to help you understand and use the EZ-IO infusion system.Our collective goal has long been rapid, safe vascular access for all critical patients. Vidacare’s approach to this goal is simple – the right equipment - in the best hands – where it’s needed most.

At the completion of this program if you still have questions or concerns please call us at 1.866.479.8500 or visit our web site at www.vidacare.com

We at Vidacare appreciate what you do and the time you devote to it. Thank you for inviting us to be a member of your team!

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This Vidacare®Training PowerPoint™ was

developed as a supplement to theEZ-IO® Proximal Tibial Access

Training ProgramBecause of the unique and varied

nature of intraosseous insertion situationand patients all training programs

should be completed prior topatient treatment

IMPORTANT NOTICEPlease read the associated slide.

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EZ-IO AD IndicationsTo Gain Immediate Vascular Access in an Emergency

EZ-IO AD IndicationsTo Gain Immediate Vascular Access in an Emergency

Altered level of consciousness

Respiratory compromise

Hemodynamic instability

Altered level of consciousness

Respiratory compromise

Hemodynamic instability

Listed here are the primary indications. Can you think of specific conditions that would fit each indications?

Examples of disease states often meeting these criteria include, but are not limited to the following:

Cardiac arrest, Status epilepticus, All shock states, Arrythmias, DehydrationBurns, Drug Overdose, DKA (diabetic), Renal failure, Stroke, AMI, Coma, OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema, Respiratory arrest, Hemophiliac crisis.

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EZ-IO AD ContraindicationsEZ-IO AD ContraindicationsFracture (targeted bone)

Previous orthopedic procedures near insertion site

Infection at the insertion site

Inability to locate landmarks or excessive tissue

Fracture (targeted bone)

Previous orthopedic procedures near insertion site

Infection at the insertion site

Inability to locate landmarks or excessive tissue

These are the contraindications. Recent fractures may cause fluid or drugs to escape into inappropriate areas – thus not reaching target tissue and possibly causing additional significant injury. Certain Orthopedic procedures at or near the insertion site. One example would be a total knee replacement. This would render the IO space inaccessible secondary to the indwelling device. Another example would be a recent (within the past 24 hours) IO placement in the same extremity. This “extra penetration” might allow extravasation (leakage) into surrounding soft tissue from the initial IO site (that has not yet closed) . Not all orthopedic procedures pose a contraindication or concern to EZ-IO usage. Examples include: prior knee surgery or even mid-shaft tibial amputations (that have completely healed).Infections at the insertion site pose a risk because they could be introduced into the bone and systemic circulation. Inability to locate the landmarks could result in an attempted placement that is unacceptable and dangerous. Lastly, Excessive tissue may result in the needle set failing to reach the intraosseous space.

With each of the possible complications above the provider should consider alternate appropriate sites. Additionally, a risk versus benefit assessment should always be considered prior to any IO placement.

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Distal Tibia Anatomy

Note the vasculature crossing from themedullary space through the compact bone

Here we can identify the structures of the Distal Tibia. Important points to note include the ankle joint (comprised of the distal tibia, distal fibula and the talus bone. It’s important to also note the relative thin compact bone at the Distal Epiphysis (Our EZ-IO AD Distal Tibia insertion site) versus the thicker compact bone on the Diaphysis (or shaft). Lastly it’s important to identify the venous structures originating within the cancellous bone, passing through the compact bone and then continuing into the body – this connection makes IO infusion possible!

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A closer look at the anatomy

Posterior Anterior

Here we can identify the structures of the Distal Tibia in greater detail. Note that the target site has been identified in a relatively safe location. Its important to note the ankle joint (comprised of the distal tibia, distal fibula and the talus bone it both artist renderings as well as x-rays.

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Posterior

Anterior

Distal Tibia

Calcaneous

Talus

The following three slides contain images from an anatomical study conducted at the University of Texas Health Science Center in San Antonio Texas. These images are designed to assist you in defining the anatomy and relative risk of improper needle set position.

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Posterior

Anterior

Distal Tibia

Anatomical study Slide 2

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Posterior

Anterior

Distal Tibia

Anatomical study Slide 3

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Posterior

Anterior

Distal Tibia

Anatomical study Slide 4

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Observe Body Substance Isolation procedures

Anytime you are providing care to the public it is important to protect yourself as well as the patient. Practicing proper Body Substance Isolation (BSI) is vital to quality patient care and is recommended anytime the EZ-IO infusion system is in use.

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Identify distal tibia insertion site

The EZ-IO should be inserted two finger widths above the most prominent aspect of the medial malleolus.

Remember:“IF YOU WANT TO GET IN (side the bone) – THINK IN (side the leg!)”“Big Toe – GO – EZ-IO”Proper identification of the insertion site is crucial. Failure to identify the

appropriate location as specified could result in:1. Improper placement – such as the ankle joint or soft tissue.2. Prolonged insertion – resulting from an attempt to insert the EZ-IO through

thicker compact bone on the Diaphysis (shaft) rather than the thinner Compact bone closer to the epiphysis (end).

3. Complete bone perforation – resulting from an improper placement attempt along the Diaphysis (shaft) of the tibia.

Can you locate the insertion site on yourself or partner now?

For the morbidly obese patient – consider rotating the foot to the mid-line position (foot straight up and down). With the knee slightly flexed, lift the foot off of the surface allowing the lower leg to “hang” dependant. This maneuver may improve your ability to visualize and access the distal tibial insertion site.

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Clean site using aseptic technique

Clean the insertion site using aseptic technique per your local protocol.

NOTE: Following your cleaning of the insertion site you may consider administration of a local anesthetic. Infiltration of 1% Lidocaine has proven effective should this be deemed necessary (THIS PROCEDURE MUST BE APPROVED BY YOUR AGENCY, SERVICE OR INSTITUTION – INSURE THAT THE PATIENT DOES NOT HAVE ASSOCIATED ALLERGIES PRIOR TO ANY DRUG ADMISISTRATION!)

The extensive evaluation of numerous conscious patients suggest that the actual insertion of the needle set is no more painful than the insertion of a standard IV catheter - thus a local anesthetic is not usually recommended in an emergent setting.

The primary source of pain (for conscious patients) associated with this device is predominately related to the increase in intra-medullary pressure. This can be mitigated with the infusion of 2% (Preservative Free) Lidocaine given through the EZ-IO AD port (Adults - 20-40mg IO slow push. Pediatrics – 0.5mg /kg IO slow push). (THIS PROCEDURE MUST BE APPROVED BY YOUR AGENCY, SERVICE OR INSTITUTION – INSURE THAT THE PATIENT DOES NOT HAVE ASSOCIATED ALLERGIES PRIOR TO ANY DRUG ADMISISTRATION!)

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Identify correct position

Make certain that you have located the appropriate insertion site.

Stabilize the leg.

Guard against any unexpected patient movement.

Place the needle set tip on the insertion site at a 90 degree angle to the tibia and prepare to power the driver.

*For the morbidly obese patient this may require two providers. One provider to lift and support the foot (keeping the leg slightly flexed) while the other provider locates the site and inserts the EZ-IO”.

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Power EZ-IO needle set through the skin at a 90 degree angle to the bone

Check the 5 mm mark

5 mm

Insure that the needle set is at a 90 degree angle to the bone (this would be directly perpendicular to the bone itself). Additionally ensure that you have located the midline of the medial aspect of the bone. Failure to locate the midline could lead to an inadvertent posterior placement (recall that various significant anatomical structures reside in the posterior medial aspect of the lower leg)

Power the driver advancing the needle set tip to the tibia.

At this point if there is any doubt that the needle set is not long enough - verify that you can see the 5 mm mark on the EZ-IO catheter (This is the mark closest to the EZ-IO hub).

If the 5 mm mark is visible continue with insertion.

If the 5 mm mark is not visible you should abandon the procedure, (the catheter may not reach the IO space) This situation is the result of excessive “pre-tibial tissue”. (see the image in the bottom right corner of this slide) Obesity is a potential cause for excessive “pre-tibial tissue” but other conditions could present in this manner.

Return the Needle Set to the cartridge for temporary safety and then dispose of the needle set in an FDA approved bio hazard container and dress the site according to protocol. WARNING – NEVER PLACE A “USED” or OPENED CARTRIDGE BACK INTO ANY JUMP KIT, CRASH CART OR OTHER LOCATION CONSIDERED CLEAN OR STERILE – Doing so poses a potential contamination or exposure risk for both patient and provider.

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Complete insertion

In the unlikely event of a driver failure consider manual insertion

Stop when you feel the pop

Guard against unexpected patient movement

Complete the insertion. Do Not Push Down with excessive force on the driver and needle set during insertion. Moderate pressure while allowing the driver and the needle set to do the work is the safest method.

You will know you have reached the IO space when:1. There is a sudden lack of resistance -“stop when you feel the pop”2. The catheter flange gently touches the skin (in adult patients - 40 kg and greater)

*In the unlikely event of driver failure during the insertion process - consider manual completion. This can be accomplished by grasping the catheter as shown. Be certain that you have a firm grasp on both the stylet and catheter hubs. Twist the needle set back and forth (maintaining a 90-degree angle) while gently pushing into position.

* Manual insertion is considerably slower and the following should be considered:

• Failure to hold both the stylet and the catheter hubs during insertion process may lead to inadvertent catheter separation and insertion failure.

• Failure to maintain a 90-degree angle while inserting the needle set manually may lead to extravasation (Caused by the creation of a larger than needed pathway for the catheter.

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Remove driver from needle set

Stabilize needle set while disconnecting

Stabilize the needle set by holding it in position. Gently and slowly remove the driver by pulling it directly up and off. Do not “rock, twist or turn” the driver during this process as this will “lock” the needle set onto the driver by narrowing the connection.

Place the driver back in its case or cradle to prevent unintentional activation.

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Remove stylet from catheter

Never attempt to replace the stylet once removed from the catheter!

Remove the stylet from the catheter by rotating (unscrewing) the coupling end counter clockwise. Once the stylet has been released - remove it from the catheter by stabilizing the hub and then gently pulling the stylet out. Be cautious with the sharp stylet. At this point you may note blood begin to slowly fill the catheter hub. This will serve as additional confirmation of placementThe stylet tip may also be checked for the presence of blood or marrow by wiping the tip on a 4x4 or sheet. This may additionally aid in confirmation of EZ-IOplacement.

Once the stylet has been removed from the catheter - do not attempt stylet replacement. Attempted stylet replacement is contraindicated and could cause significant illness or injury!

You now have access to the vascular space! Insure that you protect the patient and the sterile connection point on the catheter hub!

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Secure stylet in ShuttleClose and place in FDA approved

bio-hazard container

Place the stylet in the opened needle set cartridge (now called the stylet shuttle).

Placing the stylet into the stylet shuttle may not be necessary if an approved bio hazard container is close at hand (example - ED treatment room or EMS Unit); and directly depositing the stylet into the bio hazard container does not pose any risk.Be certain that you do not place your fingers or hand in front of the stylet at anytime. Additionally, do not hold the stylet shuttle while placing the stylet inside. Placing the stylet inside the shuttle while holding the shuttle is similar to “recapping” and could cause injury.

Once the stylet is in the shuttle close the shuttle lid. Make certain the stylet shuttle is placed in an FDA approved bio hazard container as soon as possible.

The stylet shuttle is for temporary storage and safe transport only – The Shuttle is NOT a bio hazard container!

NEVER PLACE THE STYLET SHUTTLE (and used stylet) BACK INTO ANY JUMP KIT, CRASH CART OR OTHER LOCATION CONSIDERED CLEAN OR STERILE – Doing so poses a potential contamination risk for both patient and provider.

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DO NOT ATTACH A SYRINGE DIRECTLY TO THE EZ-IO CATHETER!

Attaching a syringe may leadto an increase in the

diameter of the insertion hole

Extravasation

DO NOT ATTACH A SYRINGE DIRECTLY TO THE EZ-IO CATHETER!

Attaching a syringe directly to the catheter may lead to:

1. A fracture in the catheter/hub assembly with subsequent removal difficulty.2. An increase in the diameter of the catheter entry point and possible

extravasation.

These problems occur primarily as the result of several factors:A. The position of the provider over the patientB. Patient movement during treatmentC. Inadvertent hand movement during injection

Immediately following EZ-IO insertion and preliminary confirmation attach the provided EZ-Connect extension set to the catheter hub’s standard luer lock to avoid complications!

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Attach EZ-Connect & Confirm Placement

Give a 10 ml syringe flush * Any IV compatible extension set will attach to the standard luer lock on the EZ-IO hub

NO FLUSH = NO FLOW

Attach the EZ-Connect extension set to the standard Luer lock & confirm placement of the catheter. This can be accomplished by identifying several important findings.

1. The catheter is firmly seated and does not move.2. You note blood at the catheter hub. 3. You are able to aspirate blood or marrow from the catheter (We recommend aspiration

of only a small amount of blood due to its extremely viscous nature). 4. Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or

around the tissue. CAUTION : Conscious patients will experience pain with infusion prior to Lidocaine! Flow rates may be slow or non existent prior to the 10 ml bolus.

• You may have checked the stylet tip for blood prior to placing it in the stylet shuttle or bio hazard container.

Other indicators of proper placement include:• You may notice the effects of administered drugs• X-Ray confirmation

Protect the sterile connection point on the catheter hub!

Four Important points to consider once the EZ-IO has been established:

1. Routinely reconfirm that the EZ-IO catheter is secure and in position.2. Maintain appropriate protection at the insertion site.3. Frequently monitor the EZ-IO, the fluid and the extremity.4. Remove the EZ-IO within 24 hours.

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Administer fluid or drugs

Use pressure to improve IO flow ratesReminder - flush prior to infusion

Flow rates may be slow with gravity only infusions. Consider using pressure to administer fluid or drugs. We recommend using a 250 - 300 mmHg pressure bag or infusion pump. Bolus injections generally produce the highest flow rates. High flow rates may cause pain in conscious patients. Consider appropriate pain management. 2 % (Preservative fee) Lidocaine is recommended IO.

Tibial flow rates average 2 - 40 ml/min when using a pressure bag (REMEMBER –ANATOMY, FLUSHING and PRESSURE will affect flow). During treatment, monitor the site for complications as you would any other IV or IO device.

Discontinue any treatment if complications develop with the EZ-IO infusion system.

If fluid administration set does not produce appropriate flow consider: 1. A second IO syringe bolus of 10 ml (5 ml for pediatric) through the EZ-IO

catheter.2. Gently backing the catheter out approximately 1 mm. This can be

accomplished with a 5 or 10 ml syringe. (See DEVICE REMOVAL PRIOR TO ATTEMPTING THIS MANEUVER)

3. Placement of a second EZ-IO Needle Set in the opposite extremity.

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Secure the EZ-IO ADaccording to protocol

Monitor the infusion site

Attach wristbandAttach wristband

Once the EZ-IO is in position and treatment has begun it is important to secure the tubing and, to a lesser degree, the catheter. This can be accomplished with a commercially available securing systems or tape. You may also consider a lightly rapped rolled gauze or similar bandage in situations where adhesives will not stick. (Be extremely careful that you do not create excessive circumferential pressure on the leg!)

Remember to place the EZ-IO identification bracelet on the patients wrist! This will alert future members of the health care team to the presence of an EZ-IO.

If your insertion attempt failed for any reason place the EZ-IO identification bracelet on the patient, report the complication and document accordingly. Your report, documentation and bracelet placement may prevent a repeated IO attempt on the same leg (A repeated insertion, without knowledge of the previous IO attempt, might cause extravasation and subsequent injury to the patient).

Vidacare does not recommend repeated IO attempts or placement on the same extremity within 24 hours. This recommendation appears to allow for appropriate clotting at the insertion site thus preventing the possibility of extravasation..

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Insertion Summary

This is an insertion summary. Note the simplicity of the EZ-IO infusion system.

LOCATE– CLEAN – INSERT – OPEN – FLUSH – TREAT

In seconds, complicated vascular access will become a problem of the past.

The EZ-IO provides you with “rapid vascular access when you need it most”.