When compared to IO access at the proximal tibia site, IO access at the humeral site may provide five times the flow rate.
Positioning (3 options):
1. Place the patient’s arm in adduction and internal rotation with the hand resting on the umbilicus.
2. Place the patient’s arm in adduction and internal rotation with the hand folded underneath the lower back (placing the hand under the back may be useful during CPR).
3. Extend the elbow while the arm remains adducted, then hyperpronate the arm.
Adapted from [5]
Procedure:
1. Palpate the greater tubercle of the proximal humerus and then the surgical neck below that landmark. The ideal insertion site is 1 cm above surgical neck.
2. IO drill should be placed at a 45 degree angle with the humeral head. Ensure that you have at least 5 mm left of needle length or the needle will not be long enough. (The blue IO needle that is 25 mm will have inadequate length in up to 50% of adult patients).
3. Infusion can be painful, so consider the infusion of 40 mg (2cc) of 2% lidocaine without epinephrine over two minutes. USE IV FORMULATION FOR LIDOCAINE! Let it sit for 1 minute and then flush with normal saline. If pain persists, then infuse up to another 20 mg.
4. The first-pass success rate is 96%, and the second-pass success rate 100%.2
5. There is no need to aspirate bone marrow to confirm placement – just watch for extravasation. If you do see extravasation, discontinue the infusion to avoid compartment syndrome and necrosis. All IO lines should be removed within 24 hours.
6. Studies have demonstrated safety of infusion of hypertonic saline through IO needles in animal models without tissue damage,3 but until those studies have been validated, one should exercise caution.
Adapted from [5]
Here is a video of the procedure: https://youtu.be/ExF3QJ5UxhQ
Contraindications:
– Recent fracture of humerus
– Soft tissue infection overlying insertion site
– Previous attempt at same site within 48 hours
– Inability to identify landmarks
– Prosthetic bone or joint
– Consider inserting IO elsewhere if patient has osteoporosis or inability to immobilize the limb following IO placement
For more articles on Emergency Department procedures click here.
References
- Stimac J. Resuscitation and the humeral intraosseous line. EM Resident. 2015 June 13.
- Rush S, D’Amore J, Boccio E. A review of the evolution of intraosseous access in tactical settings and a feasibility study of a human cadaver model for a humeral head approach. Military Medicine. 2014 Aug;179(8 Suppl):24-8.
- Pepitas F, et al. Use of intra-osseous access in adults: a systematic review. Critical Care. (2016) 20:102.
- Greenstein Y, et al. A serious adult intraosseous catheter complication and review of the literature. Critical Care Medicine. 2016 April 7.
- EZIO-ACEP-FactSheet0624c
Brian
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3 Comments
ablumenberg · April 25, 2016 at 10:52 pm
I think IOs are fantastic resuscitation lines — but it’s unusual to use them on adult patients with a pulse. In pulseless patients there’s a lot of activity at the head and trunk, be it airway maneuvers, cpr, monitor placement, etc. One of the advantages of tibial or femoral lines is they utilize unclaimed real estate — a tibial IO can be placed without physically blocking someone else performing another critical task.
Nice post! I’ll keep this in my mind next resuscitation.
iandesouza · April 26, 2016 at 5:33 am
For emergent access, if IO access is an option, the femoral line may not be the way to go. Here is a study that compared IO to CVC placement:
Lee PM, Lee C, Rattner P, et al. Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies. Crit Care Med. 2015;43(6):1233-1238.
Mean placement times were significantly shorter for intraosseous than for central venous catheter (1.2 vs 10.7 min; p < 0.001). There were a total of 33 intraosseous versus 169 central venous catheter attempts with fewer attempts on average per patient during intraosseous placement (1.1 vs 2.8; p < 0.001).
Also, the close proximity of the greater tubercle of the humerus to the heart may allow for more rapid infusion of medications into the central circulation which may be desired for patients in pulseless arrest. And infusion may be better tolerated by patients when compared to the tibial sites (both from unpublished reports).
Anonymous · April 27, 2016 at 9:27 pm
Love the humeral site especially when flying in an AStar. The IV tubing port when tibial placed makes access difficult and most times requires getting out of belt. Plus the delivery time is much more rapid.