EZ-IO By Elspeth Richardson

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 1980’s 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 1 - Advanced cardiac life support guidelines. Amanagement of cardiac arrest. Circ 2005; 112-IV, 57-66.

Science? Access through BV’s in BM held open by rigid non-collapsible bony wall (don’t 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 can’t be given via ET Lasts 24-48hrs 3 - Orlowski, JP, Porembka, DO, Gallagher, JM, et al. Comparison study of intraosseous, central IV, and peripheral IV infusions of emergency drugs. AJDC 1990; 144: 112-117 4 - Hughes, WT, Buescher, ES. Paediatric procedures, 2nd ed. WB Saunders Co 1980: 117-121. 5 - Drinker, CK, Drinker, KR, Lund, CC. The circulation in mammalian bone marrow. Am J Physiology 1922; 62: 1-92. 6 - Papper, EM. The bone marrow route for injecting fluids and drugs into the general circulation. Anesthesiology 1942; 3: 307-313.

Why? “The Golden Hour” - potential for saving critically ill patients at it’s optimum Significant numbers don’t receive necessary pre-hospital therapy due to difficult IV access1 Access can be achieved in <1min without serious complications assoc with central lines 1- Lewis, FRL. Prehospital IV fluids therapy: physiology and computer modeling. J Trauma 1986; 26: 804-11.

When? APLS: Recommended technique for access in paediatric cardiac arrest; otherwise recommended if >3 attempts or >1.5mins 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 2 - Rosetti, V, Thompson, RM, Abrahamian C, et al: Difficulty and delay in intravascular access in paediatric patients. Ann Emerg Med 1984; 13: 406.

How? Little training required, good success rate (95% or more) in <60secs 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 >3mg/kg/24hrs) --> then, after 15-30secs, give 10ml 0.9% saline flush Need pressure bag - flow rate alters by 69-92ml/min 1 -  Frascone RJ.  Jensen J.  Wewerka SS.  Salzman JG. Use of the pediatric EZ-IO needle by emergency medical services providers.   Pediatric Emergency Care.  25(5):329-32, 2009 May.

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 1 - Ong ME.  Chan YH.  Oh JJ.  Ngo AS.   An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO.   American Journal of Emergency Medicine.  27(1):8-15, 2009 Jan.

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

Device? Manual device / impact driven device (‘bone injection gun’ - spring-loaded needle) / powered drill (EZ-IO - in anyone >3kg)) Pink - 3-39kg Blue - >40kg Yellow - prox humerus >40kg, or much subcutaneous tissue

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!

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 1 - Rosetti, VA, Thompson, BM, Miller, J, et al. Intraossesous infusion: an alternative route of paediatric IV access. Ann Emerg Med 1985; 14: 885-8.