Priority 5 – Vascular Access

Following the Paramedic-3 trial it was concluded that an intraosseous first strategy did not improve 30-day survival, but did reduce the proportion of patients achieving a return of spontaneous circulation. Consideration should therefore be taken on first line vascular access including external jugular access in cardiac arrest if competently trained.

EZ-IO

The EZ-IO System provides peripheral venous access with central venous catheter performance.

Intraosseous access (IO access) involves inserting a catheter into the medullary space of a long bone, providing access to the systemic vasculature. Like intravenous access, IO medications can bypass first-pass metabolism and have maximum bioavailability.

Indications

Indications for establishing IO access include:

Failure to gain intravenous access and urgent vascular access required
Cardiac arrest situations where IV access is not feasible or IV access has failed (common in pre-hospital practice)

Contraindications

Relative contraindications to establishing IO access include:

Inability to accurately identify landmarks at the chosen anatomical site
Long bone fracture
Vascular injury to the extremity
Previous orthopaedic procedure (e.g. prosthetic knee when selecting the proximal tibia site) or previous intraosseous attempt at that site in the previous 24 hours)
Overlying skin infection

These videos will demonstrate the effective insertion at various anatomical sites.

Arrow EZ-IO Proximal Tibia Insertion Site Identification – Adult

The proximal tibia IO insertion site is approximately 2cm medial to the tibial tuberosity, or 3 cm below the patella and approximately 2cm medially, along the flat aspect of the tibia.

Identify the insertion site with the leg extended.

When using this site, avoiding the epiphyseal growth plate is important. This can be done by correctly landmarking the site.

EZ-IO Proximal Tibia Insertion Technique – Adult

The proximal humerus IO insertion site is located 1-2cm above the surgical neck of the humerus. To identify the insertion site:

Place the patient’s hand over the abdomen (elbow adducted and humerus internally rotated). Place your palm on the patient’s shoulder anteriorly. The area that feels like a “ball” under your palm is the general target area. You should be able to feel this ball, even on obese patients, by pressing deeply.
Place the ulnar aspect of your hand vertically over the axilla. Place the ulnar aspect of your other hand along the midline of the upper arm laterally.
Place your thumbs together over the arm. This identifies the vertical line of insertion on the proximal humerus.
Palpate deeply up the humerus to the surgical neck. This may feel like a golf ball on a tee- the spot where the “ball” meets the “tee” is the surgical neck. The insertion site is 1 to 2cm above the surgical neck, on the most prominent aspect of the greater tubercle.
The needle tip is inserted at a 45-degree angle to the anterior plane and posteromedial.

Paediatric Site Selection