1. EZ-IO Honolulu EMS ProtocolTM
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 or visit our web site at
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.
June 2013 TM

2. Review of Intraosseous Access
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
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 for the latest important information!

3. 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

4. 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

5. Landmarks: 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 or turn to page 8 in the Training Manual.
To order a mannequin visit SAWBONES® (
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

6. Actual insertion sites located (Fingers on insertion sites)
The EZ-IO™ should be inserted two finger widths bellow the patella (kneecap) and one finger medial (toward the inside) to the tibial tuberosity.
“IF YOU WANT TO GET IN (side the bone) – THINK IN (side the leg)!”
“Big Toe (side of the leg) GO - EZ-IO”
Proper identification of the insertion site is crucial. Failure to identify the appropriate location could result in:
Improper placement – such as the knee joint or soft tissue.
Prolonged insertion – resulting from an attempt to insert the EZ-IO™ through compact (thick) bone on the Diaphysis (shaft) rather than the Cortex (thin) bone closer to the epiphysis (end).
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?
Here is an important training tip – Have a student “cross” his or her legs. Now can the “provider” identify the insertion site! Initially this might seem tricky because the relative position of the legs and insertion site has changed!
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 tibial insertion site.
Training Manual Revision B Pages 16 & 19
Actual insertion sites located
(Fingers on insertion sites)

7. Clean site using aseptic technique
Clean well
*Hold leg
Still!
Find
landmarks
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!)
Extensive evaluation on numerous conscious patients suggest that the actual insertion of the needle set is no more painful than the insertion of an IV catheter.
The primary source of pain (for conscious patients) associated with this device is predominately associated with the increase in intra-medullary pressure. This can be mitigated with the infusion of 2% (Preservative Free) Lidocaine given through the EZ-IO™ port (20-50mg IO slow push).
Training Manual Revision B Page 20

8. Power EZ-IO™ Needle Set to the bone at a 90 degree angle
Insure that the needle set is at a 90 degree angle to the tibia. (This would be directly perpendicular to the bone itself).
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.
Dispose of the needle set in an FDA approved bio hazard container and dress the site according to protocol.
Training Manual Revision B Page 21
Check the 5 mm mark !
If the skin is to thick needle won’t reach the inner bone canal and IV won’t run

9. Make sure needle you can see the 5 mm line with the needle inserted in the skin and touching bone
Insure that the needle set is at a 90 degree angle to the tibia. (This would be directly perpendicular to the bone itself).
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.
Dispose of the needle set in an FDA approved bio hazard container and dress the site according to protocol.
Training Manual Revision B Page 21
Check the 5 mm mark !
If skin is to thick needle won’t reach the inner bone canal and IV won’t run

10. Stabilize leg Guard against unexpected patient movement !
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 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 and inserts the EZ-IO™
Training Manual Revision B Page 21
Insure that the needle set is at a 90 degree angle to the tibia. So the needle goes into the marrow and doesn’t splinter or crack the bone!

11. In the unlikely event of a driver failure consider manual insertion
Complete insertion
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.
2. The catheter flange gently touches the skin.
*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. (Slide # 18)
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. Slide # 45 as well as Supplemental Slides # 55 and 62).
*The manual insertion technique is not located in the training manual
Training Manual Revision B Page 21
In the unlikely event of a driver failure consider manual insertion