EZ-IO Honolulu EMS Protocol Part 1 TM The Vidacare EZ-IO™ Training Program is designed to help you understand and use the EZ-IO™ infusion system. Throughout this PowerPoint™ presentation you will note civilian, military, hospital and pre-hospital medical professionals caring for those in need. This multi-specialty approach is important to you for two reasons: First, emergency care today, more than ever is about teamwork. Second, though each of us may work in different environments our approach to, and problems with vascular access are similar. With this in mind - sharing and participating in education and training programs such as this further enhances our combined ability to care for the most seriously ill or injured. 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. Associated with this program is a complete training system. This includes the Directions For Use (DFU’s), Training Manual, Instructor Manual, Quick Reference Card, Removal Poster, PowerPoint™ Presentation. (also available are Transparencies and 35 mm Slides upon special request), Training Video (available as DVD or VHS), Training Mannequins, Training Needle Sets, Complete Web Site with instructor resource center and finally a 24 hour emergency support telephone line. 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! Training Manual Revision B Pages 7 - 8 Honolulu EMS Review Joseph Lewis, M.D. Alan Young, MICT TM

Review of Intraosseous Access History Indications Contraindications Possible Complications Landmarks Cleaning & Maintaining Battery Changing Can you summarize the EZ-IO™ infusion system? The above seven points were emphasized in this training program. Would you like to review any particular area? Why go IO ? Slide # 4 Training Manual pgs 9 -10 Insertion site Slide # 11 – 16 Training Manual pgs 16 & 19 EZ-IO System Slide # 17 – 20 Training Manual pgs 6 & 37 Indications Slide # 22 – 23 Training Manual pgs 17 & 19 Contraindications Slide # 24 Training Manual pgs 18 & 19 Usage Slide # 21 – 44 Training Manual pgs 21 -28 Complications of IO Slide # 45 Training Manual pg 26 Cleaning & Maintaining Slide # 46 Training Manual pg 27 Battery Changing Slide # 47 Training Manual pg 28 (All Training Manual pages refer to Revision B) Have you checked for EZ-IO™ training and usage updates? Visit our web site update section at www.vidacare.com for the latest important information!

The History of Intraosseous Use 1922 - Circulation of the sternum proposed as a route to administer blood – Drinker. 1936 - Confirmation of long bone as a site for vascular access – Tocantins. 1942 - Circulation times between IV & IO routes confirmed as essentially the same – Papper. 1940’s - 1950’s - IO extensively used and written about. WW II - over 4000 cases. 1960’s - No civilian EMS - “ IO becomes the lost procedure”. 1980’s - Present - “Rediscovery” & IO development. Listed here are some of the important research and developmental milestones in the evolution of IO use. A reference section is located in the Training Manual. Do date there are more than 250 papers related to IO use or research. Training Manual Revision B Pages 11 - 12

EZ-IO™ Contraindications Fracture of the tibia or femur Previous orthopedic procedures Pre-existing medical condition Infection at the insertion site Inability to locate landmarks Excessive tissue over the insertion site 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. 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). A risk versus benefit assessment should always be considered prior to insertion. Pre-existing medical conditions such as tumors and peripheral vascular disorders could interrupt or prevent the flow of fluids. Infections at the insertion site pose a risk because they could be introduced into the bone and systemic circulation. Inability to locate the EZ-IO™ landmarks could result in an attempted placement that is unacceptable and dangerous. Lastly, Excessive tissue over the insertion site may result in the needle set failing to reach the intraosseous space. Training Manual Revision B Pages 18 & 19

Possible complications of IO Extravasation Dislodgment Compartment Syndrome Fracture Pain Reduced Flow Bone Infection Extravasation: (leakage) The EZ-IO™ reduces this possibility because of the precise rotational method used to insert the needle set – the EZ-IO™ catheter has a very snug fit once placed in the bone. Dislodgment: The EZ-IO™ infusion system is designed to be low profile – this limits accidental movement, additionally the actual method of insertion also enhances the catheter fit against the bone – this, including the flat aspect of the flange, limits motion or accidental dislodgment. Compartment Syndrome: Because the EZ-IO™ insertion method decreases the possibility of extravasation, the likelihood of swelling to the point of compartment syndrome (excessive constricting pressure in the soft tissue - leading to a decrease in circulation and possible loss of extremity) is significantly diminished. As with any vascular access device one MUST always maintain a watchful eye for complications. Fracture: The EZ-IO™ infusion system is unique in that the insertion method requires limited pressure on the bone. The driver itself utilizes an orthopedically proven safe technique to power through the bone without the use of excessive force in any direction. As Dr. Larry Miller puts it – “A kinder, gentler way”. Pain: IO placement and its use can cause discomfort. You could consider a local anesthetic for conscious patients (caution – allergies) however, clinical experience has demonstrated that EZ-IO™ insertion is no more painful than a standard IV catheter placement. One important facet about the EZ-IO™ infusion system is it’s speed of insertion (average insertion is approximately 3 seconds). Less time inserting translates to less pain. We have noted in clinical studies that there is considerable pain for conscious patients associated with the infusion of fluid. 20 – 50 mg of 2% (Preservative free) Lidocaine IO has proven helpful in reducing or eliminating the patients discomfort. Additional findings suggest that the initial administration of Lidocaine or fluid for conscious patients should be given slowly. Reduced Flow Rate: At times you may experience flow rates significantly lower than expected, The first consideration should be the possibility of inadequate initial flushing. Consider a second 10 ml Syringe Flush or Bolus. You may additionally try gently backing out the catheter approximately 1mm. Lastly, the establishment of a second EZ-IO™ catheter on the opposite leg should also be considered as a viable option. Infection: Extensive experience with thousands of children and adults demonstrates a low incidence of infection (0.6%). These infections are usually not serious and can be treated with device removal and antibiotics. Once the EZ-IO has been placed (and the patient stabilized) it is recommended that prophylactic antibiotic therapy be initiated. The EZ-IO should be removed within 24 hours Training Manual Revision B Page 26

CARDIOPULMONARY ARREST EZ-IO™ Honolulu EMS Indication When Traditional Access is not Possible in a Coded patient CARDIOPULMONARY ARREST 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, Dehydration Burns, Drug Overdose, DKA (diabetic), Renal failure, Stroke, AMI, Coma, OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema, Respiratory arrest, Hemophiliac crisis Please review the Protocol Development Guideline located on page 42 of the Training Manual Revision B. Training Manual Revision B Pages 17 & 19

Easy Safe Fast Cardiac Arrest EZ-IO Why go EZ-IO™? This is a wonderful question and there are four straight forward answers to it! Fast. Precious time is often wasted looking for peripheral veins that may or may not be accessible. Equally frustrating in certain difficult situations is central venous access - which could mean more lost time and or a significant risk of infection for the patient. We know that without access the critical patient usually cannot receive drugs or fluid. Failing to gain access might mean the difference between pain and suffering or life and death. With the EZ-IO™ infusion system time is on your side! Easy. Multiple IV attempts usually means multiple providers and catheters – this spells exposure and infection risk for the providers and the patient. With one EZ-IO™ infusion system and seconds you will most likely have easy access thus eliminating the pressure of IV failure. Safe. In hostile situations such as those in tactical environments, extrications and MCI’s, the EZ-IO™ limits your exposure and the effort needed to treat on the go! The bottom line, if time matters, then the EZ-IO™ in your hands is the answer! Shock. If the patient presents in shock the peripheral veins have often collapsed (usually the result of blood or fluid loss, lack of vascular tone, respiratory complications or cardiac failure). Gaining vascular access with the patient in this condition can be extremely difficult. The IO space is considered a Non-Collapsible vein (explanation to follow) and the EZ-IO™ helps you gain fast, safe and easy access to it! Training Manual Revision B Page 9

The EZ-IO™ Infusion System Actual Needle Set The EZ-IO™ Infusion system. Consisting of the: EZ-IO™ Dirver EZ-IO™ Needle Sets – contained in safety sealed cartridges EZ-IO™ Wrist bands (Not Pictured) EZ-Connect™ (See page 23 & 25 of the Training Manual - Rev B) IMPORTANT SAFETY CONSIDERATION – The EZ-IO™ infusion system has a separate TRAINING NEEDLE SET. This training needle set is colored RED and IS NOT FOR ACTUAL PATIENT USE. Training needle sets are not sterile or safety sealed. They are intended for training only and should never be placed inside a kit intended for actual patient care. Training Manual Revision B page 6 Training Needle Set

(with safety cap removed) Driver Attached Needle Set (with safety cap removed) Battery Cap Trigger This is the EZ-IO™ Driver with an attached needle set (safety cap is removed). Note that the driver is ergonomically designed to fit comfortably into your hand! Handle

Finding the EZ-IO insertion site anterior tibia tubercle and one finger breadth over. OK, now it is time to look at the EZ-IO™ insertion site. Do you have our EZ-IO™ Training mannequin? To see the mannequin visit our web site Training Section at www.vidacare.com or turn to page 8 in the Training Manual. To order a mannequin visit SAWBONES® (www.sawbones.com). Our mannequins offers a realistic, cost effective, safe platform to routinely teach adult Tibial EZ-IO™ placement! Training Manual Revision B Pages 16 and 19