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Proximal HumerusTraining Program

Proximal HumerusTraining Program

This Vidacare® EZ-IO® Proximal Humerus Access Supplemental Training Program is designed to help you understand and use the EZ-IO infusion system in an FDA cleared location. Our collective goal at Vidacare remains rapid, safe, effective vascular access for all critical patients. Vidacare’s approach to this goal is simple –the right equipment - in the best hands – where it’s needed most.

At the completion of this supplemental training program if you still have questions or concerns please call us at 1.866.479.8500 or visit our website at www.vidacare.com

We at Vidacare appreciate what you do and the time you devote to it. Thank you for inviting us to be a member of your team!

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This Vidacare®Training PowerPoint™ was

developed as a supplement to theEZ-IO® Proximal Tibial Access

Training ProgramBecause of the unique and varied

nature of intraosseous insertion situationand patients all training programs

should be completed prior topatient treatment

IMPORTANT NOTICEPlease read the associated slide.

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EZ-IO AD IndicationsTo Gain Immediate Vascular Access in an Emergency

EZ-IO AD IndicationsTo Gain Immediate Vascular Access in an Emergency

Altered level of consciousness

Respiratory compromise

Hemodynamic instability

Altered level of consciousness

Respiratory compromise

Hemodynamic instability

Listed here are the primary indications. Can you think of specific conditions that would fit each indications?

Examples of disease states often meeting these criteria include, but are not limited to the following:

Cardiac arrest, Status epilepticus, All shock states, Arrythmias, DehydrationBurns, Drug Overdose, DKA (diabetic), Renal failure, Stroke, AMI, Coma, OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema, Respiratory arrest, Hemophiliac crisis.

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EZ-IO AD ContraindicationsEZ-IO AD ContraindicationsFracture (targeted bone)

Previous orthopedic procedures near insertion site

Infection at the insertion site

Inability to locate landmarks or excessive tissue

Fracture (targeted bone)

Previous orthopedic procedures near insertion site

Infection at the insertion site

Inability to locate landmarks or excessive tissue

These are the contraindications. Recent fractures may cause fluid or drugs to escape into inappropriate areas – thus not reaching target tissue and possibly causing additional significant injury. Certain Orthopedic procedures at or near the insertion site. One example would be a total knee replacement. This would render the IO space inaccessible secondary to the indwelling device. Another example would be a recent (within the past 24 hours) IO placement in the same extremity. This “extra penetration” might allow extravasation (leakage) into surrounding soft tissue from the initial IO site (that has not yet closed) . Not all orthopedic procedures pose a contraindication or concern to EZ-IO usage. Examples include: prior knee surgery or even mid-shaft tibial amputations (that have completely healed).Infections at the insertion site pose a risk because they could be introduced into the bone and systemic circulation. Inability to locate the landmarks could result in an attempted placement that is unacceptable and dangerous. Lastly, Excessive tissue may result in the needle set failing to reach the intraosseous space.

With each of the possible complications above the provider should consider alternate appropriate sites. Additionally, a risk versus benefit assessment should always be considered prior to any IO placement.

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Orient your arm to this position for a discussion on Humeral Anatomy

Place the hand over the umbilicusfor better positioning and safety

Place the hand over the umbilicusfor better positioning and safety

Elbow should remain adductedAs well as on the

stretcher or ground(Posteriorly located towardThe back rest of your chair)

Elbow should remain adductedAs well as on the

stretcher or ground(Posteriorly located towardThe back rest of your chair)

To begin the discussion on humeral access we must first position the arm for maximum humeral head exposure. First, adduct the humerus then posteriorly locate the elbow toward the back rest of your chair (or floor if you are laying down). Next, place the patient’s forearm (more specifically the hand) on the patient’s abdomen – at or near the umbilicus. This will provide for a more prominent insertion site as well as ensure protection for the vital neurovascular structures located under the patient’s arm.

Important note: By placing the hand on the umbilicus (rather than the entire forearm across the abdomen) you will be able to retain the elbow on the stretcher or the ground and maximize your approach to the proximal humerus.

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Proximal Humerus Anatomy

Lesser TubercleLesser Tubercle

Intertubercular GrooveIntertubercular Groove

Greater TubercleGreater Tubercle

coracoid processcoracoid process

acromionacromion

humeral headhumeral head

humeral shafthumeral shaft

The important anatomy of the proximal humerus is relatively easy to understand and appreciate -* provided that the model or patient is in a supine position (or at a minimum leaning back in their chair - with shoulders against the back rest) and the arm adducted with the elbow posteriorly located prior to any palpation attempt.

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Insertion siteInsertion site

Insertion site

Insertion site

In these two images the provider can visualize the insertion site and the relative lack of critical structures near that specific location.

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Studies conducted at the University of Texas Health Science Center San Antonio, Texas

This EZ-IO proximal humerus study at the University of Texas Health Science Center in San Antonio provides an exceptional presentation of the value and effectiveness of this approach. *IO fluid administration via the proximal humerus reaches the heart within seconds!

Note that you can clearly see the EZ-IO catheter attached to an extension set with fluid being pushed in real time. Flow rates above 120 ml/min have been observed in humans.

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Studies conducted at the University of Texas Health Science Center San Antonio, Texas

Comprehensive anatomical reviews of the human shoulder and the associated structures of the proximal humerus were undertaken by the University of Texas Health Science Center’s Department of Radiology, Department of Anatomical Services and the Vidacare Corporation.

The associated insertion site and the methods for safely identifying that structure are contained within this supplemental training program. These methods represent the true spirit of scientific cooperation for the improvement of emergent care.

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Proximal Humerus Site

This is slide 1 of 3 in a series demonstrating an anatomical review of the proximal humerus insertion site.

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Proximal Humerus Site

This is slide 2 of 3 in a series demonstrating an anatomical review of the proximal humerus insertion site.

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The greater tubercle insertion siteThe greater tubercle insertion site

Note index finger in the intertubercular grooveNote index finger in the intertubercular groove

Needle set should never enter or be medialto the intertubercular groove !

Needle set should never enter or be medialNeedle set should never enter or be medialto the intertubercular groove !to the intertubercular groove !

Proximal Humerus Site

This is slide 3 of 3 in a series demonstrating an anatomical review of the proximal humerus insertion site.

Note that the gloved finger in the above image is actually resting in the intertubercular groove or sulcus.

This 3 slide series demonstrated the large insertion site area that is relatively devoid of critical structures.

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Identification of the Sulcus (Optional)

Laterally and medially rotatingthe forearm will enable you to

palpate the intertuberculargrove or sulcus

Laterally and medially rotatingthe forearm will enable you to

palpate the intertuberculargrove or sulcus

Providers may consider confirming the location of the intertubercular groove or sulcus by laterally then medially rotating the forearm while palpating just medially to the greater tubercle. This optional identification maneuver could be performed if the operator had concern about the location of the greater tubercle

Note that following the bicep’s midline to the humeral head will also place you directly over the sulcus.

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Insertion site

Insertion site

Arm abducted and laterally rotated inthis image to expose nerves and blood vessels

located medial to the lesser tubercle

Arm Arm abductedabducted and laterally rotated inand laterally rotated inthis image to expose nerves and blood vesselsthis image to expose nerves and blood vessels

located medial to the lesser tuberclelocated medial to the lesser tubercle

abductedabducted

Laterally rotatedLaterally rotated

Right Axillary RegionRight Axillary Region

To avoid these structures arm MUST be adductedand medially rotated during EZ-IO insertion

To avoid these structures arm MUST be To avoid these structures arm MUST be adductedadductedand and medially rotatedmedially rotated during EZduring EZ--IOIO insertioninsertion

With the arm abducted and the laterally rotated you can appreciate the significant anatomical structures located under the arm. This neurovascular network can be protected during humeral head IO access by simply adducting the arm and placing the hand near the umbilicus.

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Insertion SiteIdentification Procedure

OK, now it is time to look at the EZ-IO AD Humeral Head insertion site.

IMPORANT QUESTION: Do you have our EZ-IO AD Humeral Head Training Mannequin? To see our mannequins visit Vidacare’s website Training Section at www.vidacare.com There is a link directly from our website’s mannequin page to the “EZ-IO® company page” at SAWBONES®. You can also simply enter www.sawbones.com

Each of our mannequins offers a realistic, cost effective, safe surrogate to routinely teach the EZ-IO system and placement for both the Tibial and Humeral Head locations.

*Our relationship with Sawbones® was specifically created to keep training cost low by directly linking you to the mannequin source.

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Expose shoulder and adduct the armPatient should be in the supine position

Elbow should remain on stretcher or groundElbow should remain on stretcher or ground

The patient should be in a supine position (or at a minimum the elbow should be placed posteriorly six to eight inches). With the elbow posteriorly placed (by gravity or effort) the humeral head becomes easily visible. Inability to properly position the patient’s arm could lead to insertion failure.

Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. (With the patient in this position you may immediately note the humeral head on the anterior-superior aspect of the upper arm or anterior-lateral shoulder).

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Note that arm is adducted withthe elbow posteriorly placed!

Note that arm is adducted withthe elbow posteriorly placed!

The Proximal Humerus insertion site is found “slightly anterior to the arms lateral midline”

Right armAdult male

A 1. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. (With the patient in this position you may immediately note the humeral head on the anterior-superior aspect of the upper arm or anterior-lateral shoulder)

Note that the humerus has been outlined and clearly rests anterior to the arms lateral midline.

Do not attempt insertion medial to the intertubercular Groove or the Lesser Tubercle (Defined by the RED CIRCLE in the 3 D drawing). Insertion medial to the Lesser Tubercle can injure nerves, arteries and veins!

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The Proximal Humerus insertion site

Note that arm is adducted withthe elbow posteriorly placed!

Note that arm is adducted withthe elbow posteriorly placed!

Note that the insertion site is found anterior to the arms

lateral midline!

Left armMannequin

anterior posterior

A 1. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. (With the patient in this position you may immediately note the humeral head on the anterior-superior aspect of the upper arm or anterior-lateral shoulder)

Note that the humerus has been outlined and clearly rests anterior to the arms lateral midline.

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To identify the proximal humerus insertion siteFirmly palpate the humeral shaft with thumb progressing superiorly

toward the humeral head - palpating for the greater tubercle

Place the patient in a supine position!

This is the preferred method for locating the humeral head insertion site.

A 2. Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or humeral head. As you near the shoulder you will note a protrusion. This is the base of the greater tubercle insertion site.

A 3. With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself.

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Confirm identification of the greater tubercle insertion site with additional palpation!

With firm palpation you shoulddistinctly feel the greater tubercle

Once you have identified the greater tubercle - confirm the specific insertion site by palpation of the greater tubercle’s outer margins ultimately resting your finger on the most prominent aspect of that structure – the EZ-IO AD insertion site.

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Alternate Insertion Site Identification Procedure

This alternate method of identification can be used in associationwith the preferred method to ensure proper placement

This alternate method of identification can be used in associationwith the preferred method to ensure proper placement

This is an alternate method for locating the proximal humerus. It may be used independently or in association with each the preferred method for a higher degree of insertions site confidence.

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Identify the lateral shoulderPlace hand on lateral aspect of shoulder - palpate for “two bumps”

or “walk” fingers laterally along clavicle to the lateral shoulder

Palpate for the coracoid process and the acromionPalpate for the coracoid process and the acromion

Patient should be in a supine position

B 1. Identify two land marks on the lateral shoulder consisting of the acromion and the coracoid process. This can be accomplished by placing one hand on the lateral superior aspect of the patient’s shoulder and palpating for the protrusions. Identifying the coracoid process and the acromion can also be accomplished by “walking” your index and middle finger along the clavicle to the shoulder’s lateral end.

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Identify the coracoid process & acromion

coracoid processcoracoid process

acromionacromion

B 2. Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process and the acromion. One can envision the location of this site by creating a “triangle” - the upper portion of connecting the coracoid process and the acromion while the “point” reaches inferiorly and slightly anteriorly - approximately two finger widths along the midline (between the coracoid and the acromion).

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Identify the greater tubercle insertion site Approximately two finger widths inferior to the coracoid

process and the acromion - along the humeral midline

Patient and provider size should be considered when applying this method Patient and provider size should be considered when applying this method

B 3. This image shows the “two finger widths” distance to the insertion site.

CAUTION – This alterative method does not take into account extremely muscular individuals that might possess larger upper arm musculature. Extreme caution should be exercised when utilizing this identification technique.

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Confirm identification of the greater tubercle insertion site with additional palpation!

With firm palpation you shoulddistinctly feel the greater tubercleWith firm palpation you should

distinctly feel the greater tubercle

Once you have identified the greater tubercle - confirm the specific insertion site by palpation of the greater tubercle’s outer margins ultimately resting your finger on the most prominent aspect of that structure – the EZ-IO AD insertion site.

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Insertion site identification summary

A 1 A 2 A 3

B 1 B 2 B 3

The patient should be in a supine position

A/B 1. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground. Forearm resting on the abdomen (With the patient in this position you may immediately note the proximal humerus on the anterior-superior aspect of the upper arm or anterior-lateral shoulder)

A 2. Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or insertion site. As you near the shoulder you will note a small protrusion. This is the base of the greater tubercle insertion site.

A 3. With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself.

Alternatively:B 2. Identify two land marks on the lateral shoulder consisting of the acromion and the

coracoid process. This can be accomplished by placing one hand on the lateral superior aspect of the patient’s shoulder and palpating for the protrusions. Identifying the coracoid process and the acromion can also be accomplished by “walking” your index and middle finger along the clavicle to the shoulder’s lateral end.

B 3. Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process and the acromion (anterior to the arms lateral midline) One can envision the location of this site by creating a “T” - the upper portion of the letter connecting the coracoid process and the acromion while the “leg” reaches inferiorly and slightly anteriorly - approximately two finger widths along the midline between the two structures. Another way to envision this location is to create an inverted triangle between the aforementioned structures.

Do not attempt insertion medial to the greater tubercle! (RED CIRCLE!)

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Confirm insertions site arm positioning

Place the hand overthe umbilicus for betterpositioning and safety

Place the hand overthe umbilicus for betterpositioning and safety

Elbow should remainon the stretcher or ground for stability

Elbow should remainon the stretcher or ground for stability

With firm palpationyou should distinctly

feel the greater tubercle

With firm palpationyou should distinctly

feel the greater tubercle

Once the insertions site has been identified ENSURE that the patient’s forearm (more specifically the hand) is on the patient’s abdomen – at or near the umbilicus. This will provide for a more prominent insertions site as well as protect vital neurovascular structures located under the patient’s arm.

Important note: By placing the hand on the umbilicus (rather than the entire forearm) you will be able to retain the elbow on the stretcher or the ground and maximize your approach to the proximal humerus.

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EZ-IO Proximal Humerus Insertion

Now let’s take a look at the procedures for actual EZ-IO proximal humeral placement.

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Proper identification of the greater tubercle insertion site is necessary

Reminder: With proper orientation and firm palpation you should be able to distinctly feel the greater tubercle

Reminder: With proper orientation and firm palpation you should be able to distinctly feel the greater tubercle

Discussion: The greater tubercle insertion site appears as a round prominence on the lateral anterior – superior aspect of the patient’s arm. Another way to envision this site is to imagine “breaking in a door”. As you flex your bicep, turn slightly sideways and lean forward you are placing the proximal humerus on a collision course with the object in the way. Important: Superior to the greater tubercle insertion site is the bursa (tissue surrounding the humeral joint). Located within the intertubercular groove are tendons. Medial to the lesser tubercle (and a relative safe distance from the insertion site) are vessels and nerves. For this reason it is important that you do not attempt insertion of any IO device without positive, confirmed identification of the greater tubercle.

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Clean site using aseptic technique

Clean site using aseptic technique according to local protocol.

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Stabilize and insert the EZ-IO Needle Set

Ensure a 90°entry into the greater tubercleEnsure a 90°entry into the greater tubercle

Stabilize the arm and place the EZ-IO - maintaining a 90 degree angle during the insertion process.

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Additional Insertion Option

Emergency OnlyEmergency Only

Ensure that you maintain a 90 degree angle to the boneEnsure that you maintain a 90 degree angle to the bone

EZ-IO manual insertion can be accomplished with relative ease.

Speed of penetration will depend on the degree of clockwise – counterclockwise wrist rotation as well as the amount of gentle downward force applied during the process.

DO NOT APPLY EXCESSIVE DOWNWARD FORCE DURING INSERTION!Allow the semi-rotational action of your wrist combined with the cutting ability of specialized needle tip to penetrate the bone. Uncomplicated manual insertions are directly related to ability and technique - NOT direct force!

Applying excessive force, failing to maintain a 90 degree angle or inadvertently rocking the assembly may lead to a widening of the catheter entry point and subsequent extravasation or bending of the needle set.

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Stabilize catheter and remove driver

Failure to stabilize the catheter during driverremoval - may lead to dislodgement

IMPORTANT - Stabilize the needle set prior to any attempt at removing the driver. The Humeral cortex can be considerably “less dense” and failure to stabilize the catheter may cause inadvertent dislodgment. As patients advances in age - bone density continues to decrease and humeral stability must routinely be assessed.

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Stabilize hub and remove stylet

Place the stylet in the opened needle set cartridge (now called the stylet shuttle).

Placing the stylet into the stylet shuttle may not be necessary if an approved bio hazard container is close at hand (example - ED treatment room or EMS Unit); and directly depositing the stylet into the bio hazard container does not pose any risk.Be certain that you do not place your fingers or hand in front of the stylet at anytime. Additionally, do not hold the stylet shuttle while placing the stylet inside. Placing the stylet inside the shuttle while holding the shuttle is similar to “recapping” and could cause injury.

Once the stylet is in the shuttle close the shuttle lid. Make certain the stylet shuttle is placed in an FDA approved bio hazard container as soon as possible.

The stylet shuttle is for temporary storage and safe transport only – The Shuttle is NOT a bio hazard container!

NEVER PLACE THE STYLET SHUTTLE (and used stylet) BACK INTO ANY JUMP KIT, CRASH CART OR OTHER LOCATION CONSIDERED CLEAN OR STERILE – Doing so poses a potential contamination risk for both patient and provider.

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Confirm placement and FLUSH catheterFlush with 10 ml of saline

NO FLUSH = NO FLOWFlush with 10 ml of saline

NO FLUSH = NO FLOW

Secure catheter in positionSecure catheter in position

Attach the EZ-Connect extension set to the standard Luer lock & confirm placement of the catheter. This can be accomplished by identifying several important findings.

1. The catheter is firmly seated and does not move.2. You note blood at the catheter hub. 3. You are able to aspirate blood or marrow from the catheter (We recommend aspiration

of only a small amount of blood due to its extremely viscous nature). 4. Drugs or fluids flow without difficulty – there are no signs of extravasation (leakage) in or

around the tissue. CAUTION : Conscious patients will experience pain with infusion prior to Lidocaine! Flow rates may be slow or non existent prior to the 10 ml bolus.

• You may have checked the stylet tip for blood prior to placing it in the stylet shuttle or bio hazard container.

Other indicators of proper placement include:• You may notice the effects of administered drugs• X-Ray confirmation

Protect the sterile connection point on the catheter hub!

Four Important points to consider once the EZ-IO AD has been established:

1. Routinely reconfirm that the EZ-IO AD catheter is secure and in position.2. Maintain appropriate protection at the insertion site.3. Frequently monitor the EZ-IO AD, the fluid and the extremity.4. Remove the EZ-IO AD within 24 hours.

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Infuse medications and fluids as directedUse pressure to improve flow rates

PRESSURE = BETTERFLOW

PRESSURE = BETTERFLOW

* If you need a blood sample for lab analysis – we recommend drawing blood directly from the EZ-Connect with a syringe. Be certain to adequately flush the tubing after the sample is obtained.

Prior to any drug or fluid administration be certain to Syringe flush the EZ-IO catheter with 10 ml of fluid. NOTE: THERE IS A DISTINCT DIFFERENCE BETWEEN THE “SYRINGE FLUSH OR BOLUS” DESCRIBED ABOVE AND FLUID “GIVEN OR PUSHED WITH AN ADMINISTRATION SET”. This difference relates specifically to: The pressures generated by the syringe – clearing the “pathway for treatment” (Which is necessary because of the anatomy and nature of the IO space) Versus the relatively slow, low pressure “supportive administration” of fluids given over time.

““NO FLUSH = NO FLOWNO FLUSH = NO FLOW””Failure to “flush” may result in a limited or no flow IO situation

* If the patient is conscious slowly administer 20 - 40 mg of 2% (Preservative free) Lidocaine IO prior to the initial bolus. IO fluid administration causes pain for conscious patients and is related to intramedullary pressure. Lidocaine has proven to be an extremely effective treatment for this pain. (Utilizing a Lidocaine pre-filled syringe simplifies this process – but must be approved by protocol)

Insure that you protect the patient and the sterile connection point on the catheter hub!