TRAUMA NOTEBOOK
INTRAOSSEOUS ACCESS EZ-IO IN A PREHOSPITAL EMERGENCY SERVICE Authors: Francisco Torres, RD, Maria Dolores Galán, MD, RD, Maria del Mar Alonso, RD, Rosa Suárez, RD, Carmen Camacho, MD, and Veronica Almagro, MD, Madrid, Spain Section Editor: Kathryn Moore, RN, DNP, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC
Earn Up to 8.5 CE Hours. See page 519. Background: Several scientific and professional associations
have made reports and recommendations to regulate the use of intraosseous (IO) access as an alternative to conventional intravenous access (IA) in emergency situations when IA cannot be obtained. It has been well documented that IO access is safe and effective for fluid resuscitation, drug delivery, and blood collection. IO access is attainable in all age groups. Objective: The objective of this prospective study was to test
the use of a semi-automatic IO infusion system (EZ-IO) as an alternative to vascular access in critical patients treated in a prehospital emergency setting. Method: This prospective, cross-sectional study included patients who required immediate peripheral vascular access. This study was performed by reviewing clinical records and through a questionnaire (created by and for nurses who perform the insertion with the EZ-IO). Results: During the study period we identified 107 patients who
underwent EZ-IO insertion (114 insertions were performed). Patients were predominantly male (66%) and middle aged (mean age 56 years; range 3-94). Overall, insertion was performed via the proximal tibia (49.4%) distal tibia (25.2%), radius (14.9%), and
humerus (10.5%). During the study period, 14 insertions were performed in 2007, 44 in 2008, and 56 in 2009. A majority of patients (50.9%) had medical cardiac arrest, (25.4%) were injured trauma patients, and 12.3% had traumatic cardiac arrest. All patients were transported to a hospital with 2 sites of peripheral vascular access. The first site of access in these patients was IO (100% of cases) and the second site (in 79% of cases) was peripheral intravenous access. All EZ-IO insertions were achieved within 30 seconds and were successful upon the first attempt. Conclusion: The use of the EZ-IO provides a quick (100% performed within 30 seconds), easy, and reliable alternative to conventional venous access in critically ill patients. Traditional peripheral venous access requires a minimal preparation that can delay initial treatment in critically ill patients and cause possible interference with resuscitation. The main advantage of using EZIO is to obtain secure, immediate, noncollapsible peripheral venous access in critically ill patients. It is possible to obtain a second site of access such as peripheral venous access to administer fluids and drugs, which can improve survival rates. Key words: Infusion system (EZ-IO); Emergency; SAMUR-PC; Intraosseous access
eripheral venous access (PVA) is preferred in the treatment of critical patients in prehospital emergency settings. The use of intraosseous (IO) access is another option when PVA is difficult to achieve. IO access allows the patient to be treated immediately by facilitating the administration of fluids and medications.1,2 All drugs
P
and intravenous solutions may be administered through IO access.3 IO access was first described in 19224 and was used in a systematic manner during World War II.5 It has been used for more than 70 years as a safe alternative to PVA.2 Studies indicate that medications administered by IO access reach the cen-
Francisco Torres is Emergency Nurse, Head of Division of Quality, SAMUR-Protección Civil, and Advance Life Support Instructor, Madrid, Spain.
Veronica Almagro is Medical Doctor, SAMUR-Protección Civil, Madrid, Spain. For correspondence, write: Francisco Torres, RD, Subdireccion General SAMUR Protección Civil, Ayuntamiento de Madrid, Ronda de las Provincias, Madrid 28040 Spain; E-mail:
[email protected]. J Emerg Nurs 2013;39:511-4. Available online 23 October 2012.
Maria Dolores Galán is Emergency Nurse, Head of Division of Quality, SAMUR-Protección Civil, Madrid, Spain. Maria del Mar Alonso is Emergency Nurse, Head of Division of Quality, SAMUR-Protección Civil, Madrid, Spain. Rosa Suárez is Emergency Nurse, Quality and Environmental Management Section, SAMUR-Protección Civil, Madrid, Spain. Carmen Camacho is Medical Doctor, Head of Unit Education, SAMURProtección Civil, Madrid, Spain.
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VOLUME 39 • ISSUE 5
0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.03.005
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3. Radius 4. Humerus
Although the radius has not been described as a typical insertion site for IO access, it has been used in several cases.8,9 The EZ-IO is an IO infusion system for immediate vascular access in all patients who weigh more than 3 kg. It consists of a reusable drill (EZ-IO driver), a 15-mm needle set (PN 9018; for patients weighing 3-39 kg), a 25-mm needle set (PN 9001; for patients weighing >40 kg), and a 45-mm needle set (PN 9079; for patients weighing >40 kg when excessive tissue is present over the targeted insertion site). All the EZ-IO needles contain a stylus and a catheter. When the stylus is removed, a standard Luer-lock connector is exposed. The catheter of the EZ-IO AD (adult) is caliber 15, 25, and 45 mm long. The EZ-IO PD (pediatric) is 15 gauge. Both catheters are 304 stainless steel and are sterile and nonpyrogenic. The EZ-IO infusion system is an option for immediate vascular access, whether one is facing difficult vascular access challenges or immediate IO access is needed for critical situations and life-threatening emergencies. In this study we reviewed concurrent medical records and administered a questionnaire about the use and results of EZ-IO in patients from 2007 to 2009. The questionnaire was filled out by nurses who performed the procedure. The objective of this prospective study is to describe the use of a semi-automatic IO infusion system (EZ-IO) as an alternative to vascular access in critical patients treated in a prehospital emergency setting. Method FIGURE EZ-IO questionnaire.
tral venous circulation faster than by PVA but at the same level of concentration.3 IO access is attainable in all age groups.3,6,7 SAMUR-Civil Protection (SAMUR-PC) is the prehospital urban emergency service that responds to patients within the city of Madrid. Approximately 120,000 patients are treated by this service every year. SAMUR-PC began using IO devices (Cook-type needles) in 1995. In 1998, after the evolution of new technologies, use of the Bone Injection Gun was implemented. In January 2007, use of EZ-IO was implemented. The following anatomic locations can be used for puncture: 1. Proximal tibia 2. Distal tibia
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This descriptive and prospective study was approved by the SAMUR-PC Scientific Committee and complies with medical records data protection. Insertion of an IO device does not require patient consent because it is an established SAMUR-PC procedure.10 The study consisted of patients in the city of Madrid, Spain, who were assisted by SAMUR-PC and required IO access during treatment in the years 2007 to 2009. Included in the study were all critical patients who underwent OI access during treatment because conventional venous access (PVA) initially was impossible to achieve. Patients of all ages were included in the study. We considered patients to be critically ill if one of the following conditions occurred: 1. Respiratory problems: oxygen saturation
