EZ-IO® Proximal Humerus Insertion Site Identification – Infant/Small Child

  • 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 your hand vertically over the axilla
  • Place the ulnar aspect of your other 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 up the humerus to the surgical neck
    • This may feel like a golf ball on a tee – the spot where the “ball” meets the “tee” is the surgical neck
    • The insertion site is 1 to 2cm above the surgical neck, on the most prominent aspect of the greater tubercle

EZ-IO® Proximal Humerus Insertion Technique – Infant/Small Child

  • Prepare the site by using antiseptic of your choice
  • Use a clean, “no touch” technique
  • Remove the needle set cap
  • Point the needle set tip at a 45-degree angle to the anterior plane and posteromedial
  • Push the needle set tip through the skin until the tip rests against the bone
  • The 5mm mark must be visible above the skin for confirmation of adequate needle set length
  • Gently drill, immediately release the trigger when you feel the loss of resistance as the needle set enters the medullary space
    • Avoid recoil – do NOT pull back on the driver when releasing the trigger
  • Hold the hub in place and pull the driver straight off
  • Continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations
    • The catheter should feel firmly seated in the bone (1st confirmation of placement)
  • Place the stylet in a sharps container
  • Place the EZ-StabilizerTM dressing over the hub
  • Attach a primed EZ- Connect®  extension set to the hub, firmly secure by twisting clockwise 
  • Pull the tabs off the EZ-Stabilizer dressing to expose the adhesive, apply to the skin
  • Aspirate for blood/bone marrow (2nd confirmation of placement)
  • Secure the arm in place across the abdomen

 Recommended Anesthetic for Infant/Child Responsive to Pain:

  • Observe recommended cautions/contraindications to using 2% preservative and epinephrine free lidocaine (intravenous lidocaine)
  • Confirm lidocaine dose per institutional protocol

Usual initial dose is 0.5mg/kg, not to exceed 40mg

  • Prime EZ-Connect extension set with lidocaine

Note that the priming volume of the EZ-Connect is approximately 1.0mL 

For small doses of lidocaine, consider administering by carefully attaching syringe directly to needle hub (prime EZ-Connect with normal saline)

  • Slowly infuse lidocaine over 120 seconds

Allow lidocaine to dwell in IO space 60 seconds   

  • Flush with 2-5 mL of normal saline
  • Slowly administer subsequent lidocaine (half the initial dose) IO over 60 seconds

Repeat PRN

  • Consider systemic pain control for patients not responding to IO lidocaine

Infant/Child Unresponsive to Pain

  • Prime EZ-Connect extension set with normal saline
  • Flush the IO catheter with 2-5 mL of normal saline
  • Connect fluids if ordered, infusion may need to be pressurized to achieve desired rate
  • Assess for any signs of extravasation/complications

Should patient develop signs that indicate responsiveness to pain, refer to section “Recommended anesthetic for infant/child responsive to pain”

EZ-IO® Removal Technique

  • Remove EZ-Connect and EZ-Stabilizer dressing
  • Stabilize catheter hub and attach a Luer lock syringe to the hub
  • Maintaining axial alignment, twist clockwise and pull straight out
    • Do not rock the syringe
  • Dispose of catheter with syringe attached into sharps container

Lidocaine dosing recommendations were developed based on the research below.  For additional references, research and dosing charts, please visit http://www.eziocomfort.com

  • Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good; easing IO pain and pressure. JEMS 2010;35(9):58-69*
  • Ong MEH, Chan YH, Oh JJ, Ngo AS-Y. An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. Am J Emerg Med 2009;27:8-15*
  • Fowler RL, Pierce A, Nazeer S et al. 1,199 case series: Powered intraosseous insertion provides safe and effective vascular access for emergency patients. Ann Emerg Med 2008;52:S152*
  • Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma. 2009; 67: 606-11*
  • Wayne MA. Intraosseous vascular access: devices, sites and rationale for IO use. JEMS 2007;32:S23-5.
  • Frascone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care 2007;11:164-71*
  • Fowler R, Gallagher JV, Isaacs SM, et al. The role of intraosseous vascular access in the out-of-hospital environment (resource document to NAEMSP position statement). Prehosp Emerg Care 2007;11:63-6
  • Miller L, Kramer GC, Bolleter S. Rescue access made easy. JEMS 2005;30:S8-18*
  • Davidoff J, Fowler R, Gordon D, et al. Clinical evaluation of a novel intraosseous device for adults: prospective, 250-patient, multi-center trial. JEMS 2005;30:S20-3*
  • Gillum L, Kovar J. Powered intraosseous access in the prehospital setting: MCHD EMS puts the EZ-IO to the test. JEMS 2005;30:S24-6*
  • Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-osseous access (EZIO®) for resuscitation: UK military combat experience. JR Army Med Corps 2008;153(4):314-6.
  • Hixson R. Intraosseous administration of preservative-free lidocaine. http://www.vidacare.com/files/Hixson-Lidocaine-%20032012.pdf. Accessed November 22, 2013.

*Research sponsored by Vidacare Corporation

Vidacare disclaims all liability for the use, application or interpretation of this information in the medical treatment of any patient.