1. Maryland EMSC Program Vascular Access in Children: Intraosseous Procedure Update: “The Reasons Why” Maryland Medical Protocol and Continuing Education

2. Maryland EMSC Program Objectives n Discuss the indications and contraindications for the use of Intraosseous Access n Discuss fluids and medications that can be administered via an IO line n Demonstrate proper site selection per Maryland Medical Protocol n Demonstrate proper technique for insertion and stabilization

3. Maryland EMSC Program Topics of Discussion This program will discuss/demonstrate the following: IndicationsContraindicationsComplicationsTechnique Medication and Fluid Administration Case Studies

4. Maryland EMSC Program At the end of the course the provider will have a better understanding of pediatric vascular access and the use of IO access.

5. Maryland EMSC Program Vascular Access IV : 2 large bore catheters Upper extremity or Lower extremity Lower extremity IO: Maryland Protocol : Tibia sites < 6 years proximal tibia < 6 years proximal tibia > 6 years distal tibia > 6 years distal tibia upper lower anatomy

6. Maryland EMSC Program Keys to IV Success in Children  Have all equipment ready.  Have 2 (3) pairs of extra hands.  TELL THE TRUTH - IVs hurt.  Distract young children. * Involve older children.  2 attempts or 90 seconds * If child is awake and stable, ask another provider to attempt IV insertion. * If child is unconscious and/or unstable go to IO.

7. Maryland EMSC Program IO Indications Unavailability of vascular access or following 2 unsuccessful IV attempts for a patient in the following categories Unavailability of vascular access or following 2 unsuccessful IV attempts for a patient in the following categories  Cardiac arrest  Profound hypovolemia  Life-threatening illness/injury requiring immediate fluid or medication

8. Maryland EMSC Program IO Contraindications  Conscious patient with stable vital signs  Peripheral vascular access readily available  Fracture of the extremity  Previous IO attempts in the same extremity  Cellulitis at the intended IO site  Osteogenesis Imperfecta (OI) or other bone disorder

9. Maryland EMSC Program Potential Complications of IO Infusion  Infection  Extravasation of fluid  Fat embolism  Compartment syndrome

10. Maryland EMSC Program Tissue Extravasation

11. Maryland EMSC Program What Can Be Administered Through an IO Fluids Medications D5W Atropine Bretylium Normal saline Adenosine Calcium D5 1/4 NSS D50* Dopamine D5 1/2 NSS Epinephrine Dobutamine D10W Lidocaine Furosemide Ringer’s Lactate Naloxone D5/Ringer’s Sodium Bicarbonate Blood/ volume expanders

12. Maryland EMSC Program Equipment Required  IO/bone aspirating needle  Betadine/alcohol to cleanse site  Fluid  Administration set  Stopcock/T connector (if available)  10 cc syringe  Tape and 4x4s to secure line  Pressure device  Board splint

13. Maryland EMSC Program NEVER cover an extremity that has an IO needle placed in it.

14. Maryland EMSC Program Volume Resuscitation for Patients in Shock 20 cc/kg Ringer’s Lactate Bolus PUSH REASSESS Vascular Status Repeat 20 cc/kg Bolus RL Radio report should include the number and volume of boluses.

15. Maryland EMSC Program “C” is for Circulation SHOCK : SHOCK : Inadequate tissue perfusion to meet the metabolic demands of the body

16. Maryland EMSC Program Pediatric Circulation Estimates for Resuscitation Blood Volume = 80 cc/kg of body Weight Weight in kg = 8 + (2 x Age in years ) Systolic BP = 80 + (2 x Age in years) Systolic BP = 80 + (2 x Age in years)

17. Maryland EMSC Program “C” is for Circulation Early signs of SHOCK in Children: ã LOC : Anxious, Irritable, and Lethargic ã Respiratory Rate : Increased (Tachypnea) ã Heart Rate : Increased (Tachycardia) ã Central Pulse : Normal ã Peripheral Pulse : Weak ã Skin : Pale and Cool ã Capillary Refill : 3 - 5 seconds (normal = 2) ã BP : Normal for Age

18. Maryland EMSC Program Capillary Refill

19. Maryland EMSC Program “C” is for Circulation LATE signs of SHOCK in Children: ã LOC : Unresponsive ã Respiratory Rate : Very fast and then slow or none ã Heart Rate : Very fast ã Central Pulse : Weak ã Peripheral Pulse : Absent ã Skin : Very Pale, Mottled, Blue ã Capillary Refill : greater than 5 seconds ã BP : Low for Age (hypotension is a very late sign)

20. Maryland EMSC Program Management of Shock ã Airway ã Breathing - 100 % oxygen ã Vascular Access IV IO ã Volume resuscitation ã Initiate warming measures

21. Maryland EMSC Program Maryland IO Protocol as of 7/2000 Over 6 years: distal tibia Under 6 years: proximal tibia

22. Maryland EMSC Program Lower Leg X-ray With an IO

23. Maryland EMSC Program IO Placement in a Toddler

24. Maryland EMSC Program Intraosseous Infusion: Distal Tibia Site

25. Maryland EMSC Program IO Placement in a School-Age Child

26. Maryland EMSC Program IO with a Stop-cock The stop-cock is OFF to the syringe

27. Maryland EMSC Program IO with a Stop-cock The stop-cock is OFF to the IV tubing

28. Maryland EMSC Program Securing an IO

29. Maryland EMSC Program Case Study 1 n A previously well 3 - year-old has tonic clonic jerks separated by about 3 seconds. n ETA: 3 minutes after dispatch from the 911 center n EMS observes the child is in a postictal state. n RR is 44, pulse is 140, Temperature is 40 0 C/ 104 0 by report, BP is 120/76. n What would you do next???? n Does this child need an IO??

30. Maryland EMSC Program Case Study 2 n EMS is dispatched to a pediatric call for seizures. n A 4 -year- old child is having a seizure, and the family reports 12 minutes of seizure activity. The child has a history of seizures since birth. n RR is 12, pulse is 90, BP is 80/40, temperature is 37 0 C/ 98.6 0. n What would you do next???? n Does this child need an IO??

31. Maryland EMSC Program Case Study 3 n 5 -year-old male is struck by an auto while riding his bike. He is thrown 15 feet and lands on his head. He has a hematoma to the right side of his head and is unconscious and unresponsive to verbal and painful stimuli. n He has a RR 8, Pulse 160, BP of 150/60. n What would you do next???? n Does this child need an IO??

32. Maryland EMSC Program IO Frequently Asked Questions n Can a patient receive blood through an IO? n Yes, blood can be administered through an IO. n Can blood be drawn from an IO? n Yes, lab work can be drawn from an IO.

33. Maryland EMSC Program

34. Upper Extremity Vascular Access Site

35. Maryland EMSC Program Lower Extremity Vascular Access Site

36. Maryland EMSC Program Veins of the upper and lower extremities