IO cannulation

Question 1

Why do we use IO

Answer 1

• fast, reliable and easy to do
• bones are highly vascular
• bones are non-collapsible

Question 2

Indications for IO

Answer 2

• requirement for immediate vascular access when peripheral access has failed
  SWAST guidelines:
• life threatening presentation
• IV not established after 2 attempts or within 90 seconds
• considered alternative access eg. EJV

Question 3

Contraindications of IO

Answer 3

-fracture of target bone
-excessive tissue or absence of adequate landmarks
-infection at area of insertion
-previous significant orthopaedic procedure at site
-prosthetic limb or joint
-IO in target bone within last 48 hours

Question 4

Steps for IO access

Answer 4

1. consent and explain procedure if pt conscious
2. hand hygiene and PPE
3. identify appropriate site
4. gather equipment and prime infusion line with sodium chloride 0.9%
5. identify landmarks
6. choose appropriately sized needle
7. prep skin with alcohol wipe (same as IV)
8. test driver by pulling trigger then attach needle to driver then remove protective cover
9. stabilise insertion site with non dominant hand
10. without pulling trigger insert needle until hit bone
11. check angle of drill and that one black line is visible above skin
12. pull trigger and apply light pressure until needle is pulled into bone and then release trigger
13. once in bone, disconnect driver, stabilise needle with non dominant hand, unscrew and remove stylet place in sharps bin
14. place stabiliser dressing over needle
15. attach administration set and flush with 5-10ml adults (2-5ml paeds) saline
16. peel covers off back of stabiliser dressing and fix down
17. once placement confirmed after flushing, fix cannula down with remainder of dressing, label time and date
18. document procedure

Question 5

Adult IO sites in order of preference

Answer 5

• proximal humerus
• proximal tibia
• distal tibia

Question 6

Paed IO sites in order of preference

Answer 6

• distal femur (if under 6)
• proximal tibia
• distal tibia

Question 7

Equipment needed for IO

Answer 7

• fluid bag
• giving set
• 3 way tap
• easy IO extension set
• alcohol wipe
• driver
• IO needle
• syringe- 5-10ml
• IO dressing
• sharps bin

Question 8

What to do if patient conscious

Answer 8

• give lidocaine
• start with higher dose and let it sit for 60 seconds
• flush the needle
• then administer lower dose over 30 seconds
• monitor patients obs and ECG during insertion

Question 9

IO landmarking proximal humerus

Answer 9

-place pts hand over their abdomen (like its in a sling)
-place palm of hand over ball at anterior surface of shoulder
-place hands either sides of shoulder to give vertical line of insertion
-palpate up the humerus to the spot the ball meets the ‘tee’
-insertion site is 1-2cm above this
-insert needle at 45 degree angle towards opposite hip

Question 10

Proximal tibia landmarking

Answer 10

Adult
-find patella, feel down to top of tibia, go 1cm medially, that’s the place of insertion
-if can’t find site, go 3cm below patella
-insert 90 degrees to bone
Children
-1cm below tibial tuberosity or 2cm below patella
-insert 90 degrees to bone

Question 11

Distal femur landmarks (children u6)

Answer 11

-1-2cm above patella, 1cm medially
-make sure leg is straight
-insert at 90 degrees to bone

Question 12

Distal tibia landmark (not authorised in SWAST)

Answer 12

Adult:
-3cm proximal to inner ankle bone (medial malleolus
Children
-1-2cm proximal to ankle bone

-insert 90 degrees to skin

Question 13

IO needle sizes and how to choose

Answer 13

15mm- pink
25mm- blue
45mm- yellow (usually for proximal humerus or obese adults)

-tip of needle through skin and touching bone, if can’t see one black line above the skin, must choose longer needle

Question 14

Complications of IO

Answer 14

-osteomyelitis (infection of bone)
-extravasation (drilled through other side of bone/ in wrong place causing swelling)
-dislodgement
-fracture of target bone

Question 15

IO removal adults

Answer 15

-attach luer lock syringe rotating whilst pulling outwards
-tends to happen after cardiac arrest when pt died