Use of IO devices is limited to patients who are unresponsive or hemodynamically unstable; and then, only when less invasive means are ineffective or not available (e.g., IM Glucagon, IN Narcan or Versed).
A For an adult in cardiac arrest, the preferable order of vascular access is EJ, AC, and proximal humeral IO.
A An adult cardiac arrest patient’s circulation differs from a pediatric cardiac arrest patient’s, and also differs from an adult in deep shock. With the approval of the department’s Medical Director, it is recommended that the proximal humerus be the site for IO insertions for adults in cardiac arrest. IV or IO accesses below the diaphragm may be ineffective for patients greater than 8 years old who are receiving CPR. Flow rates are better in the proximal humerus due to decreased bone density. The longer yellow (45 mm) needle should be used for humeral IOs in adults.
- In summary:
Find the "flat spot" on the medial aspect of the tibial shaft two finger widths below (distal) the tibial tuberosity. Remember, "Big Toe IO" means to look on the big toe side of the leg for the tibial plateau (the flat spot). Use a similar technique as for the Pediatric tibial insertion.
- Use the blue IO needle for 5-30 kg.
- Use the pink IO needle for 0-5 kg.
- IO Insertion at Proximal Tibia Site
1. Identify the tibial tuberosity by palpating just below the knee.
2. Locate the consistent flat area of bone 2 cm distal and slightly medial to the tibial tuberosity (to avoid growth plate).
3. Support flexed knee with towel under calf.
4. Prep the skin and insert needle according to manufacturer’s directions.
5. Use 10-150 caudal angulation to further decrease risk of hitting growth plate.
6. Needle will stand up on its own with proper placement.
7. Attach syringe and aspirate bone marrow (to further confirm placement).
8. Connect the IV line. If flow is good and extravasation is not evident secure needle with gauze pads and tape.
9. A pressure bag may facilitate infusion.
10. A Lidocaine 2% 1.5 mg/kg up to 100 mg via IO for pain associated with infusion.
P Lidocaine 2% 0.5 mg/kg (max 100 mg) via IO for pain associated with infusion.
NOTE: The administration of other drug therapy should not be delayed due to the administration of Lidocaine for pain management.
The greater tuberosity is located by placing the patient’s hand on their navel and relaxing their shoulder and elbow. Draw a straight line between the coracoid process and the acromion. Complete the drawing of a perfect triangle by using the previous line as the base of the triangle and extending the "point" of the triangle over the humeral head. The site is at the downward point of the triangle.
A IO Insertion at Humeral Head Site
1. Position patient so shoulder is adducted (moved toward the middle of the body) and the greater tuberosity is most prominent by lying patient supine, arm at their side with palm on their navel.
2. Palpate proximal humerus and identify the greater tuberosity.
3. Prep the skin.
4. Insert the needle at a 45 degree angle to the frontal plane and aimed at the inferior portion of the sternum.
5. Needle will stand up on its own with proper placement.
6. The yellow IO needle should be used for humeral IOs.
7. Attach syringe and aspirate bone marrow to further confirm placement.
8. Connect the IV line. If flow is good and extravasation is not evident, secure needle with gauze pads and tape.
9. Pressure bags may facilitate infusion.