EMS Pocket Guide Rev A Dec 2015

ARROW® EZ-IO® SYSTEM PROXIMAL HUMERUS LANDMARKING A

A: 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.

B

You should be able to feel this ball, even on obese patients, by pushing deeply. B: 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.

C

C: Place your thumbs together over the arm. This identifies the vertical line of insertion on the proximal humerus. D: Palpate deeply up the humerus to the surgical neck.

D

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 2 cm above the surgical neck, on the most prominent aspect of the greater tubercle.

EZ-IO SYSTEM INSERTION TECHNIQUE STEP 1: Locate the insertion site.

Pediatrics only

STEP 2: Clean insertion site per hospital protocol. Stabilise extremity.

STEP 3: Gently press needle through the skin until the tip touches the bone. The 5 mm black mark on the cathetermust be visible prior to insertion. Squeeze the trigger, apply gentlesteady pressure.

STEP 4: Stabilise hub and remove driver and stylet. Place stylet in an appropriate sharps container.

STEP 5: Place the EZ-Stabilizer ® Dressing over the catheter hub.

EZ-IO SYSTEM APPLICATION AND REMOVAL STEP 6: Attach primed EZ-Connect ® Extension Set, firmly secure to catheter hub with clamp open.

STEP 7: Remove adhesive from back of EZ-Stabilizer Dressing and apply to skin.

STEP 8: Confirm placement. Flush the EZ-IO Catheter with normal saline (5–10 ml for adults; 2–5 ml for infants/children). May require multiple flushes. Prior to flush, consider intraosseous 2 % preservative- and epinephrine-free lidocaine IO for patients responsive to pain – follow institutional protocols/policy.*

STEP 9: Deliver medication and fluids as ordered. If adequate IO flow rates cannot be achieved with an infusion pump, a pressure bag should be considered.

REMOVAL STEP 10: Using a sterile luer-lock syringe as a handle, attach to hub of needle, maintain alignment and rotate clockwise while pulling straight up. Avoid rocking the needle on removal, dispose of catheter with syringe attached in an approved sharps container.

EZ-IO SYSTEM INSERTION SITES The EZ-IO Intraosseous Vascular Access System offers multiple sites for safe, fast vascular access in emergent, urgent or medically necessary cases.

EZ-IO SYSTEM INSERTION SITES Do NOT use the powered EZ-IO Vascular Access System in the sternum

Advantages of proximal humerus site include: • Flow rates average 5 l/hr 2 • 3 seconds to heart with medication/fluids3 • Lower insertion & infusion pain 2 • Less medication required for pain management 2 • No reported compartment syndrome due to IO placement – as of Jan. 2015 Potential complications may include local or systemic infection, hematoma, extravasations or other complications associated with percutaneous insertion of sterile devices.

EZ-IO SYSTEM COMPONENTS EZ-IO® POWER DRIVER REf.

9058

QTY

EZ-IO ® power driver

1

EZ-IO® NEEDLE + STABILIZER KITS REf.

QTY

9079P

45 mm needle + stabilizer

5*

9001P

25 mm needle + stabilizer

5*

9018P

15 mm needle + stabilizer

5*

* Each Needle Set includes a Sterile 15 Ga. EZ-IO Needle, EZ-Connect Extension Set, Patient Wrist Band and Needle Vise ® Sharps Block

REFERENCE 1. Evaluation of the LMA Supreme: a sizing and troubleshooting study. Allan J. Goldman, MD,+ Daniel Langille, CRNA,+ Michael Flacco, MD,++ Michael Horn, MD,++ Roxanne Hertzog, MD++ 2. Philbeck TE, Miller LJ, Montez D, Puga T. Pain management with the use of IO. JEMS. 2010;35(9):58-69. 3. Vidacare Internal Studies (2013); data on file. Average time for medication infusion from humerus to the right atrium with EZ-IO ® Device; individual results may vary. + The University of Washington Medical Center (Seattle, WA) ++ Outpatient Anesthesia Services (Seattle, WA) (presented at the 2008 Society for Airway Management Annual Meeting)

LMA SUPREME® AIRWAY INSERTION TECHNIQUE FIGURE 1: Fully deflate the mask for insertion. Attach a syringe. Compress the distal tip of the mask with thumb and index finger. Apply slight tension to the inflation line while removing all air until a vacuum is felt. Disconnect the syringe. Generously lubricate the posterior surface of the cuff and airway tube. FIGURE 2: Place the patient’s head in a neutral or slight “sniffing” position. Hold the LMA Supreme Airway at the proximal end with the connector pointing downward to the chest and the tip of the distal end pointing toward the palate.

1

2

FIGURE 3: Press the tip of the mask against the hard palate. Maintaining pressure against the palate, continue to rotate the mask inwards in a circular motion following the curvature of the hard and soft palate.

3

FIGURE 4: Continue until resistance is felt. The distal end of the mask should now be in contact with the upper esophageal sphincter. The device is now fully inserted.

4

LMA SUPREME AIRWAY INSERTION TECHNIQUE FIGURE 5:* Maintaining inward pressure, secure the mask into position by taping cheek to cheek across the fixation tab. This should be done prior to inflation. Inflate with the minimum amount of air needed to achieve an effective seal.

5

* A lternatively, taping can be done after the esophageal seal is confirmed. Inward pressure should be applied throughout inflation and ventilation, prior to taping in place.

LMA SUPREME AIRWAY DIAGNOSTIC TESTS

After the LMA Supreme Airway is inserted, secured and inflated, diagnostic tests No. 1 and No. 2 should be performed to confirm the complete separation of the respiratory and alimentary tracts, or the LMA Supreme Airway oro­pharyngeal and esophageal seal, respectively. Diagnostic Test No. 3 is optional. DIAGNOSTIC TEST NO. 1: FIXATION TAB TEST (Recommended to confirm correct size and esophageal seal) After fixation, the taping tab should be positioned 1 to 2.5 cm from the upper lip. If the taping tab is more than 2.5 cm from the upper lip, this suggests the device may be too big. If the taping tab is less than 1 cm from the lip, this suggests the device may be too small. At no time should the taping tab be in contact with the upper lip. Use clinical judgment to replace a mask that appears too big or small. DIAGNOSTIC TEST NO. 2: GEL TEST (Recommended to confirm correct size and esophageal seal) Apply ¼ inch of (viscous) water-soluble sterile lubricant to the proximal end of the drain tube and hand ventilate. The gel should remain covered across the top of the drain

LMA SUPREME AIRWAY DIAGNOSTIC TESTS tube. This indicates that the esophageal seal has been achieved by ensuring the tip of the mask is against the upper esophageal sphincter. DIAGNOSTIC TEST NO. 3: OG TUBE PLACEMENT (OPTIONAL) (Inserting an OG tube allows the option to either suction or decompress the stomach. Successful passage of an OG tube is definitive confirmation of drain tube patency and tract separation). To facilitate gastric decompression and/or drainage, an OG tube can be placed into the drain tube of the LMA Supreme Airway and advanced into the stomach at any time during the procedure. Refer to the Sizing Guide table for maximum gastric tube sizes. The gastric tube should be well lubricated and passed slowly and carefully. Suction should not be performed until the gastric tube has reached the stomach. Suction should not be applied directly to the end of the drain tube. It is clinical preference to either remove the OG tube or leave it in place. If left in place, in the unlikely event of active or passive (non-suctioned) regurgitation, the drain tube would lose its patency.

LMA SUPREME AIRWAY SIZING GUIDE RECOMMENDED WEIGHT-BASED GUIDELINES FOR DETERMINING THE APPROPRIATE LMA SUPREME AIRWAY FOR YOUR PATIENT item number

size

patient size

max. cuff vol. (air)*

max. size og tube

175010

1

Neonates/Infants up to 5 kg

up to 5 ml

6 Fr.

175015

1.5

Infants 5–10 kg

up to 8 ml

6 Fr.

175020

2

Children 10–20 kg

up to 12 ml

10 Fr.

175025

2.5

Children 20–30 kg

up to 20 ml

10 Fr.

175030

3

Children 30–50 kg

up to 30 ml

14 Fr.

175040

4

Adults 50–70 kg

up to 45 ml

14 Fr.

175050

5

Adults 70–100 kg

up to 45 ml

14 Fr.

OG = orogastric tube * These are maximum volumes that should never be exceeded. It is recommended the cuff be inflated to 60 cm H 2O intracuff pressure.

ALTERNATIVE SIZING METHODS Oral Airway Comparison Size the oral airway according to the traditional sizing method (angle of the jaw to the corner of the mouth). Choose the appropriate size LMA Supreme Airway, based on the following: 80 mm oral airway (No.3) = Size 3 LMA Supreme Airway 90 mm oral airway (No.4) = Size 4 LMA Supreme Airway 100 mm oral airway (No.5) = Size 5 LMA Supreme Airway 1

LMA MAD NASAL ATOMIZATION DEVICE PROCEDURES STEP 1: Using the free hand to hold the occiput of the head stable, place the tip of the MAD Nasal Device snugly against the nostril aiming slightly up and outward (toward the top of the ear). Fill syringe with proper volume of medication required to treat the patient (an extra 0.1 ml should be drawn up to account for the dead space in the device). Attach the MAD Nasal Device to the syringe via luer-lock connector.

STEP 2: Briskly compress the syringe plunger to deliver half of the medication into the nostril.

STEP 3: Move the device over to the opposite nostril and, repeating steps 1 and 2, administer the remaining medication into the nostril if indicated.

LMA MAD NASAL ATOMIZATION DEVICE

MAD100

MAD140

TIPS TO IMPROVE SUCCESS Minimise volume, maximise concentration • 1⁄3 ml per nostril is ideal, 1 ml is maximum • Use the appropriately concentrated drug Maximise total mucosal absorptive surface area • Atomize the drug (rather than drip it in) to cover broad surface area • Use BOTH nostrils to double the absorptive surface area • A im slightly up and outwards to cover the turbinates and olfactory mucosa Beware of abnormal mucosal characteristics • Mucous, blood and vasoconstrictors reduce absorption • Suction nostrils or consider alternate drug delivery method in these situations

LMA® MAD NASAL™ ATOMIZATION DEVICE ORDERING INFORMATION item number

product description

qty/ box

MAD100

LMA MAD Nasal Intranasal Mucosal Atomization Device with 3 ml syringe

25

MAD140

LMA MAD Nasal Intranasal Mucosal Atomization Device with 3 ml syringe and vial adapter

25

for use with pre-loaded syringe MAD300

LMA MAD Nasal Intranasal Mucosal Atomization Device without syringe

Additional sizes and configurations are available. Call or visit our web site for more information. For use with drugs approved for intranasal delivery.

25

TELEFLEX HEADQUARTERS INTERNATIONAL, IRELAND Teleflex Medical Europe Ltd., IDA Business and Technology Park, Dublin Road, Athlone, Co Westmeath Phone +353 (0)9 06 46 08 00 · Fax +353 (0)14 37 07 73 [email protected] AUSTRALIA/NEW ZEALAND 1300 360 226 AUSTRIA +43 (0)1 402 47 72 BELGIUM +32 (0)2 333 24 60 CANADA +1 (0) 905 943 9000 CHINA (SHANGHAI) +86 (0)21 6163 0965

JAPAN +81 (0)3 6632 3600 KOREA +82 2 536 7550 MEXICO + 52 55 5002 3500 NETHERLANDS +31 (0)88 00 215 00 PORTUGAL +351 22 541 90 85

CHINA (BEIJING) +86 (0)10 6418 5699

SINGAPORE (SEA NONDIRECT SALES COUNTRIES) +65 6439 3000

CZECH REPUBLIC +420 (0)495 759 111

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SOUTH AFRICA +27 (0)11 807 4887

GERMANY +49 (0)7151 406 0 GREECE +30 210 67 77 717 INDIA +91 (0)44-2836 5040 ITALY +39 0362 58 911

SPAIN +34 918 300 451 SWITZERLAND +41 (0)31 818 40 90 UNITED KINGDOM +44 (0)1494 53 27 61

For detailed information see www.arrowezio.com Selection and use of any medication, including lidocaine, given IV or IO is the responsibility of the treating physician, medical director, or qualified prescriber and is not an official recommendation of Teleflex. This information is not intended to be a substitute for sound clinical judgment or your institution’s treatment protocols. Teleflex is not the manufacturer of lidocaine. Users should review the manufacturer’s instructions or directions for use and be familiar with all indications, side effects, contraindications, precautions and warnings prior to administration of lidocaine or any other medication. Teleflex disclaims all liability for the application or interpretation of this information in the medical treatment of any patient. For additional information, please visit www.eziocomfort.com The products in this catalogue may not be available in all countries. Please contact your local representative. All data current at time of printing (11/2015). Subject to technical changes without further notice. Needle Vise is a product of Atrion Medical Products Inc. Teleflex, Arrow, EZ-IO, EZ-Connect, EZ-Stabilizer, Hudson RCI, LMA, LMA Supreme, MAD, MAD Nasal and Rüsch are trademarks or registered (in the U.S. and/or other countries) trademarks of Teleflex Incorporated or its affiliates. © 2015 Teleflex Incorporated. All rights reserved. MC-000609

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