EZ-IO® Intraosseous Vascular Access System Procedure (Template)
Purpose
To provide procedural guidance for use and maintenance of the EZ-IO® Intraosseous Vascular Access System.
Definition
Intraosseous (IO): situated within, occurring within, or administered by entering a bone
Key Words
Intraosseous, IO, EZ-IO®, infusion, vascular access
Indications for Use
For adult and pediatric patients anytime vascular access is difficult to obtain in emergent, urgent or medically
necessary (non-emergent) cases.
Contraindications
Recent fracture of the targeted bone
Previous, significant orthopedic procedures at insertion site (e.g. prosthetic limb or joint)
IO within the past 48 hours in the targeted bone
Infection at area of insertion
Excessive tissue or absence of adequate anatomical landmarks
Equipment
EZ-IO® Vascular Access Power Driver
Appropriate length sterile EZ-IO® needle set based on clinician’s assessment of patient
EZ-Connect® extension tubing (included in sterile needle set package)
Non-sterile gloves
Chlorhexidine (e.g. ChloraPrep) or cleansing agent of choice
EZ-Stabilizer(tm) dressing
Luer lock syringe and sterile saline solution or pre-filled normal saline syringe for flush
Consider 2% preservative-free IV lidocaine without epinephrine (i.e. cardiac lidocaine,) for patients responsive
to pain
Intravenous fluid (as indicated)
Infusion pressure pump or pressure bag (if needed)
Luer lock syringes for laboratory samples (if ordered)
Procedure
Explain procedure to patient/family when possible
Obtain assistance as needed
Wash hands
Prepare syringe with appropriate volume of sterile saline solution for flush
5-10mL for adult
2-5mL for infant/child (adjust volume based on size of patient)
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Identify Insertion Site
Palpate site to locate appropriate anatomical landmarks for needle set placement and to estimate soft tissue
depth overlying the insertion site.
Proximal Humerus:
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 pushing deeply
Place the ulnar aspect of one hand vertically over the axilla
Place the ulnar aspect of the opposite 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 as you climb up the humerus to the surgical neck
It will feel like a golf ball on a tee – the spot where the “ball” meets the “tee” is the surgical neck
The insertion site is on the most prominent aspect of the greater tubercle, 1 to 2cm above the
surgical neck.
On large patients you may only palpate the most prominent aspect of the greater tubercle
If necessary, for further confirmation, locate the inter-tubercular groove:
With your finger on the insertion site, keeping the arm adducted, externally rotate the humerus 90-degrees
You may be able to feel the inter-tubercular groove
Rotate the arm back to the original position for insertion
The insertion site is 1-2cm lateral to the inter-tubercular groove
Proximal Tibia
Insertion site is approximately 2cm below the patella and approximately 2cm medial to the tibial tuberosity
(depending on patient anatomy) along the flat aspect of the tibia.
Pediatric - If NO tuberosity is present, the insertion is located approximately 2cm below the patella and 1cm
medial, along the flat aspect of the tibia. Pinch the tibia between your fingers to identify the medial and lateral
borders.
Distal Tibia
Insertion site is located approximately 2cm proximal to the most prominent aspect of the medial malleolus for
adults and 1-2cm proximal for pediatrics. Palpate the anterior and posterior borders of the tibia to assure that
your insertion site is on the flat center aspect of the bone.
Select EZ-IO® Needle Set based on patient anatomy, weight and tissue depth
Needle selection is dependent on clinical judgment
NOTE: The EZ-IO® catheter is marked with a black line 5mm proximal to the hub. Prior to drilling, with the
EZ-IO® needle set inserted through the soft tissue and the needle tip touching bone, adequate needle length is
determined by the ability to see the 5mm black line above the skin.
EZ-IO® 45mm needle set (yellow hub) should be considered for:
Proximal humerus insertion in patients 40kg and greater
Patients with excessive tissue over any insertion site
EZ-IO® 25mm needle set (blue hub) should be considered for:
Tibial insertions in patients 40kg and greater or when additional length is needed
EZ-IO® 15mm needle set (pink hub) should be considered for small pediatric patients:
Tibial insertions in patients approximately 3-39 kg, caution - consider tissue depth over insertion site
Inspect EZ-IO® needle set package to ensure sterility
Prime EZ-Connect® extension tubing with sterile saline or lidocaine as appropriate (priming volume 1.0mL)
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Consider IO 2% preservative free IV lidocaine without preservatives for patients responsive to pain
***We recommend dosages per the Hixson chart if approved by your institution***
Leave syringe attached to EZ-Connect® extension tubing
Apply clean or sterile gloves
Re-identify insertion site, if necessary
Clean site
Connect appropriate needle set to driver
Remove needle cap
Stabilize site
Gently push the needle set through the soft tissue at the insertion site until the needle set tip touches the bone
Inspect to ensure that at least one black line is visible above the skin - if no black line is visible, consider a
longer needle set or an alternative site for insertion
Penetrate the bone cortex by squeezing driver’s trigger and applying gentle, consistent, steady pressure
***Allow the driver to do the work***
Release the driver’s trigger and stop the insertion process when:
Adult patients: the hub is almost flush with the skin
Pediatric patients: you feel a decrease in resistance indicating the needle set has entered the
medullary space - stop when you feel the “pop” or “give”
Stabilize hub of the needle set with non-dominate hand, remove driver by pulling straight off
Continue to stabilize the hub of the needle set and remove stylet by turning top of needle set counter-clockwise,
then pull stylet up & out, the needle should feel firmly seated in the bone (1st confirmation of correct placement)
Immediately dispose of stylet in appropriate biohazard sharps container
Obtain blood samples for laboratory analysis if desired:
Stabilize hub of needle and connect a luer lock syringe directly to the EZ-IO® hub
Aspirate 2ml and discard or use for cultures or blood typing
Aspirate adequate volume for tests and place immediately in sample tubes
Place EZ-Stabilizer(tm) dressing over the needle hub
Attach EZ-Stabilizer(tm) dressing by pulling the tabs to expose the adhesive and adhere to skin
Attach primed EZ-Connect® extension set to the needle hub, firmly secure by twisting clockwise
If using lidocaine (patients responsive to pain), we recommend using dosage per Hixson’s chart
Slowly infuse lidocaine over 2 minutes
Allow lidocaine to dwell in IO space 60 seconds
Flush catheter vigorously with 5-10mL normal saline (adults), 2-5mL normal saline (infant/child) /adjust
volume based on size of patient
Consider administering a subsequent dose of lidocaine IO after the flush and PRN for pain
Connect fluids (if indicated) and pressurize up to 300mmHg for maximum flow, secure tubing
Humerus – ensure arm remains in place, consider application of arm immobilizer
Document date and time on armband and place on patient
Consistently monitor site and limb for extravasation or other complications
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Catheter Removal
Remove the EZ-Connect® extension set from the needle hub
Remove EZ-Stabilizer(tm) dressing
Stabilize needle hub and attach a 5-10mL sterile luer lock syringe to act as a handle
Grasp syringe, maintaining axial alignment, twist clockwise while gently pulling the needle straight out
DO NOT ROCK OR BEND THE NEEDLE DURING REMOVAL
Dispose of needle with syringe attached into a sharps container
Apply pressure to site as needed to control bleeding and apply dressing as indicated
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