Vascular Access in Children: Intraosseous Procedure Update:

1
Vascular Access in ChildrenIntraosseous
Procedure UpdateThe Reasons Why

• Maryland Medical Protocol and Continuing Education

2
Objectives

• Discuss the indications and contraindications for
  the use of Intraosseous Access
• Discuss fluids and medications that can be
  administered via an IO line
• Demonstrate proper site selection per Maryland
  Medical Protocol
• Demonstrate proper technique for insertion and
  stabilization

3
Topics of Discussion

• This program will discuss/demonstrate the
  following
• Indications
• Contraindications
• Complications
• Technique
• Medication and Fluid Administration
• Case Studies

4
At the end of the course the provider will have a
better understanding of pediatric vascular access
and the use of IO access.
5
Vascular Access

• IV 2 large bore catheters
• Upper extremity or
• Lower extremity
• IO Maryland Protocol Tibia sites
• lt 6 years proximal tibia
• gt 6 years distal tibia

upper
lower
anatomy
6
Keys to IV Success in Children

• Have all equipment ready.
• Have 2 (3) pairs of extra hands.
• TELL THE TRUTH - IVs hurt.
• Distract young children.
  Involve older children .
• 2 attempts or 90 seconds
  If child is awake and stable, ask
  another provider to attempt IV insertion.
  
• If child is unconscious and/or unstable go to
  IO.

7
IO Indications

• Unavailability of vascular access or following
  2 unsuccessful IV attempts for a patient in the
  following categories
• Cardiac arrest
• Profound hypovolemia
• Life-threatening illness/injury requiring
  immediate fluid or medication

8
IO Contraindications

• Conscious patient with stable vital signs
• Peripheral vascular access readily available
• Fracture of the extremity
• Previous IO attempts in the same extremity
• Cellulitis at the intended IO site
• Osteogenesis Imperfecta (OI) or other bone
  disorder

9
Potential Complications of IO Infusion

• Infection
• Extravasation of fluid
• Fat embolism
• Compartment syndrome

10
Tissue Extravasation
11
What Can Be AdministeredThrough an IO

• Fluids Medications
• D5W Atropine
  Bretylium
• Normal saline Adenosine
  Calcium
• D5 1/4 NSS D50
  Dopamine
• D5 1/2 NSS Epinephrine
  Dobutamine
• D10W Lidocaine
  Furosemide
• Ringers Lactate Naloxone
• D5/Ringers Sodium
  Bicarbonate
• Blood/ volume expanders

12
Equipment Required

• IO/bone aspirating needle
• Betadine/alcohol to cleanse site
• Fluid
• Administration set
• Stopcock/T connector (if available)
• 10 cc syringe
• Tape and 4x4s to secure line
• Pressure device
• Board splint

13
NEVER cover an extremity that has an IO needle
placed in it.
14
Volume Resuscitation for Patients in Shock

• 20 cc/kg Ringers Lactate
• Bolus PUSH
• REASSESS Vascular Status
• Repeat 20 cc/kg Bolus RL
• Radio report should include the number and volume
  of boluses.

15
C is for Circulation

• SHOCK
• Inadequate tissue perfusion to meet the metabolic
  demands of the body

16
Pediatric Circulation

• Estimates for Resuscitation
• Blood Volume 80 cc/kg of body Weight Weight in
  kg 8 (2 x Age in years )
• Systolic BP 80 (2 x Age in years)

17
C is for Circulation

• Early signs of SHOCK in Children
• LOC Anxious, Irritable, and Lethargic
• Respiratory Rate Increased (Tachypnea)
• Heart Rate Increased (Tachycardia)
• Central Pulse Normal
• Peripheral Pulse Weak
• Skin Pale and Cool
• Capillary Refill 3 - 5 seconds (normal 2)
• BP Normal for Age

18
Capillary Refill
19
C is for Circulation

• LATE signs of SHOCK in Children
• LOC Unresponsive
• Respiratory Rate Very fast and then slow or
  none
• Heart Rate Very fast
• Central Pulse Weak
• Peripheral Pulse Absent
• Skin Very Pale, Mottled, Blue
• Capillary Refill greater than 5 seconds
• BP Low for Age (hypotension is a very late
  sign)

20
Management of Shock

• Airway
• Breathing - 100 oxygen
• Vascular Access IV
  IO
• Volume resuscitation
• Initiate warming measures

21
Maryland IO Protocol as of 7/2000
Over 6 years distal tibia Under 6
years proximal tibia
22
Lower Leg X-ray With an IO
23
IO Placement in a Toddler
24
Intraosseous Infusion Distal Tibia Site
25
IO Placement in a School-Age Child
26
IO with a Stop-cock
The stop-cock is OFF to the syringe
27
IO with a Stop-cock
The stop-cock is OFF to the IV tubing
28
Securing an IO
29
Case Study 1

• A previously well 3 - year-old has tonic clonic
  jerks separated by about 3 seconds.
• ETA 3 minutes after dispatch from the 911 center
• EMS observes the child is in a postictal state.
• RR is 44, pulse is 140, Temperature is 40 0 C/
  1040 by report, BP is 120/76.
• What would you do next????
• Does this child need an IO??

30
Case Study 2

• EMS is dispatched to a pediatric call for
  seizures.
• A 4 -year- old child is having a seizure, and the
  family reports 12 minutes of seizure activity.
  The child has a history of seizures since birth.
• RR is 12, pulse is 90, BP is 80/40, temperature
  is 37 0 C/ 98.6 0.
• What would you do next????
• Does this child need an IO??

31
Case Study 3

• 5 -year-old male is struck by an auto while
  riding his bike. He is thrown 15 feet and lands
  on his head. He has a hematoma to the right side
  of his head and is unconscious and unresponsive
  to verbal and painful stimuli.
• He has a RR 8, Pulse 160, BP of 150/60.
• What would you do next????
• Does this child need an IO??

32
IO Frequently Asked Questions

• Can a patient receive blood through an IO?
• Yes, blood can be administered through an IO.
• Can blood be drawn from an IO?
• Yes, lab work can be drawn from an IO.

33
(No Transcript)
34
Upper Extremity Vascular Access Site
35
Lower Extremity Vascular Access Site
36
Veins of the upper and lower extremities