Fast or Easy?

Comparing Two Adult IO Infusion Devices

• James E. Pointer, MD, Deede Vultaggio, RN, Chief Robert Schnepp, EMT-P, Alvin Kleveno, EMT-P
• JEMS.com Exclusive
• 2008 Jan 23

You arrive at a post-acute-care facility where the attendants inform you of a 78-year-old female with a history of difficulty breathing. Apparently, the patient had been transferred from an acute-care hospital only 15 minutes earlier; the nurse tells you the patient is far too ill for their facility. A thorough past history is difficult to obtain, but the attendants note treatment for an infection, congestive heart failure (CHF) and hypothyroidism. Medications include amoxicillin and furosemide.

You find an elderly female, supine in bed, with an altered mental status in obvious respiratory distress. The vital signs are blood pressure: 145/105; heart rate: 105, respiratory rate: 30, and oxygen saturation: 92% on room air. Pertinent physical findings include bilateral rales one-half way up the lung fields, presacral and ankle edema and a Glascow Coma Scale of 12.

You make the diagnosis of CHF/pulmonary edema and altered level of consciousness. The protocol calls for administration of nitroglycerin, application of continuous positive airway pressure (CPAP) and small doses of IV furosemide. You and your partner search, in vain, for IV access.

Your partner pulls out what appears to be a small blue drill from the treatment kit. She attaches a needle and sterilely prepares an area over the right medial superior tibia. Within 45 seconds, a normal saline infusion and 60 mg of Lasix are flowing into the intraosseous (IO) space. Your patient’s follow-up vitals are blood pressure: 130/100, heart rate: 95, respiratory rate: 16, and oxygen saturation: 96%. You transport the patient without incident to an acute-care hospital. On the way, the patient begins to speak a few words to you and your partner. The emergency physician at the receiving hospital asks you why a needle is protruding from your patient’s right leg. You explain the rationale behind the use of the EZ-IO device for adult IO access and the emergency doc seems genuinely interested.

Even though IO access was described more than 80 years ago, only recently has the technique received serious consideration for inclusion into EMS practice. Over the past 20 years improved technologies and the need to rapidly treat ill and injured patients have resulted in a careful reconsideration of IO access in everyday medicine and paramedic care. The 2005 AHA CPR and emergency cardiac care (ECC) guidelines emphasized the futility of endotracheal administration of medications and recommended IO infusion techniques as a “rescue” access procedure. Three commercially available, FDA-approved adult IO devices are available. Because of the thickness of the bony cortex in adults, mechanical means are usually necessary for IO access. The FAST-1 device achieves access through the sternum with a spring mechanism. The Bone Injection Gun (BIG) also employs spring loading technology and is used in the more traditional, standard long-bone sites. The EZ-IO employs a battery-powered drill design to achieve long-bone site access.

Comparing the Devices

Paramedics at all 19 Alameda County Fire Department stations, in the metropolitan San Francisco Bay Area, performed a consecutive, prospective data analysis for the FAST-1 and EZ-IO devices in adult patients. Paramedics provided data on a separate, mandatory IO notification form, including patient information, which device they used and why, and whether the procedure was successful.

In many cases, the ACFD quality improvement registered nurse interviewed the attending paramedic to determine their opinions on the relative advantages or disadvantages of the two procedures. Only the medial superior tibial site was utilized. The researchers discussed training and QI considerations in a 2005 article in Fire Engineering.

Success Rates and Failures

At 97.2%, success rates for the EZ-IO device were significantly higher than those for the FAST-1 device, which had a success rate of 83.8%. AFCD personnel employed the FAST-1 device in 117 patients between Dec. 1, 2004 and Sept. 30, 2006. During this time, 48 patients died at the scene. Ninety eight attempts were successful. The majority of the failures were due to inadequate or low-flow status.  (See Table 1) The EZ-IO was utilized in 71 patients between May 1, 2006 and Feb. 4, 2007. During this time, 27 patients died at the scene. Sixty nine attempts were successful. One of the two unsuccessful attempts was due to apparent access but no flow. The other failure was due to inability to access the bone marrow in an obese patient. Two patients in the EZ-IO group had also received a FAST-1 insertion, one due to a FAST-1 failure. Patients ranged in age from 18 to 85, with an average age of 61.5 years.

On three occasions a paramedic had to be summoned to the hospital to use the included tool to remove the FAST-1 device at the direction of the emergency physician after successful infusion had taken place. FAST-1 most cases of failure, flow simply didn’t occur. There were no cases of penetration of internal organs or inaccurate placement of the FAST-1 device. Several medical practitioners complained that the device interfered with activation and performance of CPR. Finally the county medical director and other physicians felt the device appeared intimidating, and utilized a greater quantity of anchoring nails than necessary. In the end, the poor success rate doomed this device for use throughout the system

The comments from field paramedics regarding complications and failures with the FAST-1 device are instructional. “The spring-loaded device took some force to activate. I hooked up the IV solution and used the blood pressure cuff to provide extra force. There was minimal flow to the patient,” one paramedic reported. Another reported that the FAST-1 deployed well at first in an obese, elderly woman but failed. “Two rounds of meds flowed well then it became dislodged and infiltrated,” they said.

In another instance, an experienced paramedic wrote in his report of an elderly cardiac arrest patient that “FAST-1 was unsuccessful -- landmark found and injected and flushed, but the IO was not patent.”

In spite of the device’s lower success rate, most insertions were successful and uneventful. 

Unlike FAST-1, the EZ-IO was distinguished by easy and quick insertions. Only in one case was an obese patient’s subcutaneous adipose tissue so thick that the needle system was unable to penetrate the bone marrow. In the large majority of cases, paramedics noted that the device placement went well without complications and that fluids or medications infused in a satisfactory fashion. About half the EZ-IO infusions required a pressure bag or blood pressure cuff to ensure adequate flow. On one occasion the EZ-IO power unit battery appeared to be low as the device died several times, but a subsequent check didn’t reveal a problem. In many instances, paramedics noted the EZ-IO device saved time when compared to searching for a site and initiating an IV line.

Several comments from field providers confirmed the device’s success and ease of use. One paramedic reported that there was extended downtime when using with a 400-lb. patient. “EZ-IO flowed well,” another medic wrote.

In one case when application of the EZ-IO followed that of the FAST-1, the medic reported, “The FAST-1 did not work. After examining the device it looked like one of the needles was bent,” the medic wrote. “The EZ-IO worked well.”

Conclusion

As a result of the study, the county medical director implemented the EZ-IO device for the Alameda County EMS system. The device has enjoyed wide acceptance for its simple, straightforward training, ease of use and high success rates. The county plans to use EZ-IO in the pediatric population for the coming protocol year and to authorize the humeral head, and perhaps the distal tibial sites, in addition to the standard proximal tibial insertion area in the appropriate adult population. Several hospital emergency department (ED) chiefs have sought input from the EMS medical director in consideration of adding the EZ-IO to the ED armamentarium.

In an urban-suburban EMS system, the performance of the EZ-IO far exceeded that of the FAST-1 IO device. As a result of the work done by Alameda County Fire Department on the pilot study, the EMS system implemented the EZ-IO for adult IO access in Alameda County.

James E. Pointer , MD, is employed by the Alameda County Emergency Medical Services Agency. He can be reached at  james.pointer@acgov.org .

Deede Vultaggio , RN;  Chief Robert Schnepp , EMT-P and  Alvin Kleveno , EMT-P are employed by the Alameda County Fire Department. They can be reached at Deede.Vultaggio@acgov.org; Rob.Schnepp@acgov.org;  Alvin.Kleveno@acgov.org , respectively.

References

1. LaRocco BG, Wang HE: “Intraosseous infusion.” Prehospital Emergency Care. 7:280-285. 2003
2. Lavis M: “Pre-hospital adult intraosseous infusion.” Prehospital Immediate Care. 3:89-92. 1999.
3. “Guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC).” Circulation. 112(8 Supp) IV 57-66. 2005.
4. Curran A, Sen A: “Best evidence topic report. Bone injection gun placement of intraosseous needles.” Emergency Medicine Journal. 22:366. 2005.
5. Frascone R, Kaye K, Provo TA, et al: “Field trial of the FAST-1 adult intraosseous infusion system by EMT-P and EMT-I personnel.” Prehospital Emergency Care. 7:174. 2003.
6. Miller LJ, Morrisette C: “Vida-Port: An advanced easy IO device” Prehospital Emergency Care. 8(1):110-11. 2004.
7. Suprun SC, Nixon RG: “Not kids stuff anymore.” Fire EMS. 25-28, August 2006.
8. Vultaggio D, Swartzell A, Kleveno A, et al: “Sternal intraosseous access in the adult patient.” Fire Engineering . May 2005.   

ACKNOWLEDGEMENTS: