Intraosseous access

Indications

3 EZ-IO sizes

• Immediate vascular access required for administration of drugs/fluids
• Cardiac arrest, resuscitation when no other IV in place

15 Gauge IO sizes

Contraindications

• Osteoporosis
• Osteomyelitis
• Osteogenesis imperfecta
• Fractured bone
  • Extravasation of fluid can lead to compartment syndrome
• Recent IO infusion in same bone
• Cellulitis, infection, or burn, at insertion site

Equipment

• IO drill (other products/brands available)
• Appropriate IO needle with extension set (see below)
• Chloraprep or alcohol swabs
• Saline Flush
• Lidocaine (2% lidocaine without epi)

Needle Length Selection

• Visually confirm that at least 1 black line (5 mm) of the needle is visible above the skin, when the needle tip first touches bone.
  • This ensures that the needle is long enough to penetrate to the medullary cavity once fully inserted.

Based on weight of patient

• Pink 15mm (3-39kg)
• Blue 25mm (40kg and above)
• Yellow 45mm  (excessive tissue or humerus)

Site Selection

IO Site Selection

Site	Population	Priority	Needle
Proximal tibia	All ages	Alternative	15 mm / 25 mm / 45 mm
Distal femur	Pediatric <=14 years	First-line (<2 years) / Preferred	25 mm or 45 mm
Proximal humerus	Adults >14 years	Preferred for shock	45 mm

Proximal Tibia

• 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia

Proximal Humerus

• Adults only, use yellow needle
  • keep arm adducted and internally rotated (hand on bellybutton)
  • slide fingers up humerus until you feel a notch (surgical neck)
  • insert IO 1cm above surgical neck into the greater tubercle
  • immobilize arm or IO will displace (no abduction at shoulder)

Distal Femur

• For pediatric <=14 years
  • Considered by some to be first-line for <2 years
  • Faster flow and thicker cortex with higher success rates (vs proximal tibial IOs) in younger children
• 25 mm or 45 mm needle (do not use 15 mm needle for any age group)
• Minimize leg movement after placement (knee flexion can dislodge)
• Landmarks
  • Infant / toddler / school-age = 1 cm above & 1 cm medial to superior patella (with knee extended)
  • Older child = 3 cm above & 1 cm medial to to superior patella (with knee extended)

Other (Less Common)

• Sternum (Has highest flow rate of any location)
• Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
• Pelvic ASIS

Procedure

• Identify landmarks (see above)
• Clean skin
• Place appropriate needle on drill and remove safety cap
• ADVANCE needle through skin to bone
  • DRILL needle perpendicular into bone at site with gentle, constant pressure
  • When needle tip contacts bone there should be 5mm of catheter (at least one black line) visible outside of skin (if not you may need a longer needle)
  • Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
• Remove stylet
  • Caution: stylet is extremely sharp - place in sharps container
• Attach the manufacturer's extension set
  • Helpful if this is pre-flushed with saline and/or lidocaine
• Aspirate blood/marrow to confirm placement
• If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)
• Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
• Apply securing dressing

Removal

Should not be left in more than 72-96 hours and ideally removed after initial resuscitation (once more secured access is achieved)

• Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
  • Can attach syringe via luer lock to act as handle
• Apply dressing.

Complications

• Compartment syndrome
• Incomplete penetration of cortex
• Penetration of posterior cortex
• Infection (cellulitis, osteomyelitis)
• Fracture
• Growth plate damage
• Fat embolism

Labs drawn via IO

• Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
  • There is not good correlation with Sodium, Potassium, CO₂, and calcium levels.
  • Potassium is often elevated due to hemolysis
• CANNOT use IO blood for CBC
  • WBCs are higher and platelet counts are lower
• Only need to discard 2mL of blood prior to sending to lab

IO Medications

• Any medication that can be given in peripheral IV can be given through IO
  • Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line
  • RSI medications can be given through IO with the same efficacy
• Same doses as IV meds
• Follow with flush
• Drips or IV fluids should be given with pressure bag or infusion pump

IO and CT contrast

• Overall safe and effective
• Case reports with successful venous opacification in a trauma patient
• Successful CTA PE protocol reported
• Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure)

See Also

Vascular access types

• Central venous catheterization
  • Central line: internal jugular
  • Central line: subclavian
  • Central line: supraclavicular
  • Central line: femoral
  • Pediatric central line
  • Sheath introducer
• Rapid infusion catheter
• Intraosseous access
• Venous cutdown
• Umbilical vein catheterization
• Ultrasound assisted peripheral line placement
• External jugular vein cannulation
• The "Easy IJ"
• Midlines

External Links

• Teleflex EZ-IO
• Merk Manual - How To Do Intraosseous Cannulation

Videos

• EMRAP (3:12) https://www.youtube.com/watch?v=KHXSfh2ZRDM