Proximal Humerus

Training 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!

1
 This Vidacare®
Training PowerPoint™ was
developed as a supplement to the
EZ-IO® Proximal Tibial Access
Training Program
Because of the unique and varied
nature of intraosseous insertion situation
and patients all training programs
should be completed prior to
patient treatment

IMPORTANT NOTICE
Please read the associated slide.

2
 EZ-IO AD Indications
To Gain Immediate Vascular Access in an Emergency

9 Altered level of consciousness

9 Respiratory compromise

9 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, Dehydration

Burns, Drug Overdose, DKA (diabetic), Renal failure, Stroke, AMI, Coma,
OB complications, Thyroid crisis, Trauma, Anaphylaxis, CHF, Emphysema,
Respiratory arrest, Hemophiliac crisis.

3
 EZ-IO AD Contraindications
¾ Fracture (targeted bone)

¾ Previous orthopedic procedures near insertion site

¾ Infection at the insertion site

¾ 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.

4
 Orient your arm to this position for a
discussion on Humeral Anatomy

Elbow
Elbow should
should remain
remain adducted
adducted
As
As well
well as
as on
on the
the
stretcher
stretcher or
or ground
ground
(Posteriorly
(Posteriorly located
located toward
toward
The
The back
back rest
rest of
of your
your chair)
chair)

Place
Place the
the hand
hand over
over the
the umbilicus
umbilicus
for
for better
better positioning
positioning and
and safety
safety

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.

5
 Proximal Humerus Anatomy
coracoid
coracoid process
process

Lesser
Lesser Tubercle
Tubercle
acromion
acromion

humeral
humeral head
head Greater
Greater Tubercle
Tubercle

humeral
humeral shaft
shaft Intertubercular
Intertubercular Groove
Groove

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.

6
 IInnsse
errttio
ionn ssit
itee

IInns
seer
rttiioo
nn ssiit
tee

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

7
 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.

8
 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.

9
 Proximal Humerus Site

This is slide 1 of 3 in a series demonstrating an anatomical review of the proximal

humerus insertion site.

10
 Proximal Humerus Site

This is slide 2 of 3 in a series demonstrating an anatomical review of the

proximal humerus insertion site.

11
 Proximal Humerus Site
The
The greater
greater tubercle
tubercle insertion
insertion site
site

Note
Noteindex
indexfinger
fingerin
inthe
theintertubercular
intertuberculargroove
groove

Needle
Needleset
set should
should never
never enter
enter or
orbe
bemedial
medial
to
to the intertubercular groove!!
the intertubercular groove

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.

12
 Identification of the Sulcus (Optional)

Laterally
Laterally and
and medially
medially rotating
rotating
the
the forearm
forearm will
will enable
enable you
you to
to
palpate
palpate the
the intertubercular
intertubercular
grove
grove or
or sulcus
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.

13
 IInnsse
errttio
ionn sit
sitee

Right Axillary Region

aabbddu
ucctteed
d

Arm
Arm abducted
abducted and
and laterally
laterally rotated
rotated in
in
this
this image to expose nerves and blood vessels
image to expose nerves and blood vessels
located
located medial
medial to
to the
the lesser
lesser tubercle
tubercle
To
To avoid
avoid these
these structures
structures arm
arm MUST
MUST bebe adducted
adducted
Laterally
Laterally rotated
rotated and
and medially
medially rotated during
during EZ-
EZ-IO insertion
EZ-IO insertion

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 Site
Identification 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.

15
 Expose shoulder and adduct the arm
Patient should be in the supine position

Elbow
Elbow should
should remain
remain on
on stretcher
stretcher or
or ground
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).

16
 The Proximal Humerus insertion site is found
“slightly anterior to the arms lateral midline”
Right arm
Adult male

Note
Note that
that arm
arm is
is adducted
adducted with
with
the elbow posteriorly placed!
the elbow posteriorly placed!

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!

17
 The Proximal Humerus insertion site
Left arm Note that the insertion site is
Mannequin found anterior to the arms
lateral midline!

anterior posterior

Note
Note that
that arm
arm isis adducted
adducted with
with
the
the elbow posteriorly placed!
elbow posteriorly placed!

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.

18
 To identify the proximal humerus insertion site
Firmly 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.

19
 Confirm identification of the greater tubercle insertion
site with additional palpation!

With 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.

20
 Alternate Insertion Site
Identification Procedure

This
This alternate
alternate method
method of
of identification
identification can
can be
be used
used in
in association
association
with the preferred method to ensure proper placement
with 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.

21
 Identify the lateral shoulder
Place 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 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.

22
 Identify the coracoid process & acromion

coracoid
coracoid process
process

acromion
acromion

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).

23
 Identify the greater tubercle insertion site
Approximately two finger widths inferior to the coracoid
process and the acromion - along the humeral midline

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

24
 Confirm identification of the greater tubercle insertion
site with additional palpation!

With
With firm
firm palpation
palpation you
you should
should
distinctly feel the greater tubercle
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.

25
 Insertion site identification summary

A1 A2 A3

B1 B2 B3

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!)

26
 Confirm insertions site arm positioning

Elbow
Elbow should
should remain
remain
on
on the
the stretcher
stretcher or
or
ground
ground for
for stability
stability

With
With firm
firm palpation
palpation Place
Place the
the hand
hand over
over
you
you should
should distinctly
distinctly the
the umbilicus
umbilicus for
for better
better
feel
feel the
the greater
greater tubercle
tubercle positioning
positioning and
and safety
safety

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.

27
 EZ-IO Proximal Humerus
Insertion

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

28
 Proper identification of the greater tubercle
insertion site is necessary

Reminder:
Reminder:With
Withproper
properorientation
orientationand
andfirm
firmpalpation
palpation
you
you should
should be
beable
ableto
todistinctly
distinctlyfeel
feelthe
thegreater
greatertubercle
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.

29
 Clean site using aseptic technique

Clean site using aseptic technique according to local protocol.

30
 Stabilize and insert the EZ-IO Needle Set

Ensure
Ensure aa 90°entry
90°entry into
into the
the greater
greater tubercle
tubercle

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

31
 Additional Insertion Option

Emergency Only

Ensure
Ensure that
that you
you maintain
maintain aa 90
90 degree
degree angle
angle to
to the
the bone
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.

32
 Stabilize catheter and remove driver

Failure to stabilize the catheter during driver

removal - 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.

33
 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.

34
 Confirm placement and FLUSH catheter
Flush
Flush with
with 10
10 ml
ml of
of saline
saline
NO FLUSH = NO FLOW

Secure
Secure catheter
catheter in
in position
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.

35
 Infuse medications and fluids as directed
Use pressure to improve flow rates

PRESSURE = BETTER
FLOW

* 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.
FLOW”
“NO 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!

36