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Training 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 the
EZ-IO® Proximal Tibial Access
Training Program
Because of the unique and varied
nature of intraosseous insertion situation
and patients all training programs
should be completed prior to
patient treatment
IMPORTANT NOTICE
Please read the associated slide.
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EZ-IO AD Indications
To Gain Immediate Vascular Access in an Emergency
9 Respiratory compromise
9 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:
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EZ-IO AD Contraindications
¾ Fracture (targeted bone)
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
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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Anterior
Distal Tibia
Talus
Calcaneous
Posterior
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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Anterior
Distal Tibia
Posterior
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Anterior
Distal Tibia
Posterior
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Anterior
Distal Tibia
Posterior
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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.
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.
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
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 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
Stop when you
feel the pop
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.
*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 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 placement
The 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-IO
placement.
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 Shuttle
Close 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!
Extravasation
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Attach EZ-Connect & Confirm Placement
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.
• You may have checked the stylet tip for blood prior to placing it in the stylet shuttle or
bio hazard container.
Four Important points to consider once the EZ-IO has been established:
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Administer fluid or drugs
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.
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Secure the EZ-IO AD
according to protocol
Attach 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).
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Insertion Summary
This is an insertion summary. Note the simplicity of the EZ-IO infusion system.
The EZ-IO provides you with “rapid vascular access when you need it most”.
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