EMS Equipment
By Will Chapleau

Advanced Devices Help  Gain Intraosseous Access
Over the next few months, through this column I will be looking at specific companies and their missions to solve prehospital issues through their products and services. Through interviews and literature searches, I will describe the need, the company’s response, and how these products and services may help us in the field.

First up is intraosseous access.

Intravenous (IV) access is a staple of prehospital advanced life support (ALS). The controversies over fluid volumes for resuscitation and changing drug protocols notwithstanding, the expectation is that ALS brings patients in with IV access secured.

Pediatric Patients
This has long been a problem in pediatric patients with small, hard-to-get-at veins, particularly if they are dehydrated, trauma patients with vascular collapse secondary to hypovolemia and medical patients with cardiovascular failure. Intraosseous access, or IO, was presented at first as an answer to the pediatric problem, but has since expanded to adult patients.

Since 2001, Vidacare has been in the business of developing, manufacturing and marketing advanced intraosseous access devices. Based in San Antonio, Texas, its goal is to make systems that provide safe rapid vascular access.

Paramedics should be familiar with the idea of running IV fluids into bone. In patients who are dehydrated or severely hypovolemic, veins may not be accessible for starting IVs, but bone provides an alternative. The marrow of our large bones is where our red blood cells are manufactured and huge amounts of blood flow through these bones.

Accessing The Marrow
By accessing the marrow using a spinal needle or specially designed intraosseous needle, IV fluids, and even drugs, can be administered.

 

Trained EMS personnel can establish IO access at the proximal tibia or inches below the knee in the shin bone. Recent literature is describing humeral and distal femur sites as appropriate for IO access as well. (Vidacare Illustration)

The Vidacare EZ IO Driver is a battery-powered device used by medics and works like a small power drill to gain safe access to bone marrow for effective infusion.     (Vidacare Photo)

In the past, spinal needles were used to push through the bone and into the marrow. These were hollow needles with a removable core that could be removed once into the marrow so fluids could be administered. The needle was then secured to the limb. The Cook and Jamshidi IO needles were the most commonly available. Both have handles to which pressure can be applied and twist clockwise and counterclockwise to access the marrow. In the last several years, companies have developed a variety of devices specifically for intraosseous access whether in the hospital or the field.

The EZ-IO was developed by Vidacare to provide rapid safe vascular access via the intraosseous route for pre- and intra-hospital applications. In 2004, the Food and Drug Administration (FDA) approved the EZ-IO AD, the first battery-operated intraosseous access system. The device uses a specially designed drill-tipped, hollow beveled needle. The battery device, like a small power drill, allows for safe, rapid access. Within seconds, the needle can be secured through the bone and into the marrow for safe and effective infusion.

The typical site for IO access is the proximal tibia or inches below the knee in the shin bone. Recent literature is describing humeral and distal femur sites as appropriate for IO access as well.

In 2005, Vidacare received approval for use of the device in pediatric patients and for use using proximal humerus insertion. The company also makes products for bone marrow aspiration, which can be useful in obtaining stem cells.

The company describes the need for safe rapid IO access by stating that IV access is not possible in over 6 million patients every year. Thousands of deaths are attributed to this inability to gain vascular access. IO access should be an easy option, and the Vidacare device aims to make it a more likely option.

Any time vascular access is called for, but unattainable, IO is an option. While most prehospital protocols include pediatric patients, some systems do not have adult IO access protocols. In many systems, IO has become the logical and immediate next step when access to veins is not possible.

Clinical trials and Advanced Cardiovascular Life Support (ACLS) protocols have placed IO as effective as venous with drugs and fluids making their way into central circulation in seconds.

Complications of IO insertion are related to leakage out of the vascular system and dislodging of the needle, but the risk has been deemed minimal.

Training in the use of the battery-driven device is simple, and I’ve seen video of Vidacare personnel having the device used on them while describing the procedure. They describe rapid and safe access being possible in less than 10 seconds. As to pain, they report that it is no more painful than conventional IV access. The device is currently in use all over the world, and an international clinical trial is being launched to evaluate the effectiveness and safety of the device.
There are other devices for IO access to the sites discussed for this product, and also a device for sternal insertion.

More about those in subsequent columns.

Editor’s Note: Will Chapleau, who has 30 years of EMS experience, is the Advanced Trauma Life Support (ATLS) program manager for the American College of Surgeons. He is the former chief of the Chicago Heights (Ill.) Fire Department, has served since 1996 as the chairperson for the Prehospital Trauma Life Support (PHTLS) program of the National Association of Emergency Medical Technicians and has been a member of its international faculty since 1984. He is a board member of the National Association of EMS Educators.