Intraosseous (IO) access

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3 EZ-IO sizes
  • immediate access required for administration of drugs/fluids
  • cardiac arrest, resuscitaion when no other IV in place
  • IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved[1]
15 Gauge IO sizes



  • Multiple different types of IO needles and products available
  1. EZ-IO drill
  2. Appropriate IO needle with extension set
  3. Chloraprep or alcohol to clean skin
  4. Saline Flush
  5. Lidocaine (2% lidocaine without epi)

Site Selection

  1. Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
  2. Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
  3. Proximal humerus (adults only, use yellow needle)
  4. Distal Femur (generally only in infants and children)
  5. Pelvic ASIS

EZ-IO Needle selection (based on weight of patient)

  1. Pink 15mm (3-39kg)
  2. Blue 25mm (40kg and above)
  3. Yellow 45mm  (excessive tissue)


  1. Identify landmarks
  2. Clean skin
  3. Place appropriate needle on drill and remove safety cap
  4. ADVANCE needle through skin to bone
  5. DRILL needle perpendicular into bone at site with gentle, constant pressure
  6. When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)
  7. Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
  8. Remove stylet
  9. Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
  10. Aspirate blood/marrow to confirm placement
  11. 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)
  12. Flush saline through extension set to ensure good flow
  13. Apply dressing
  14. REMOVAL: detach extension tubing. place a 12mL empty syringe on IO luer lock. twist clockwise while gently and slowly applying in-line traction until removed. apply dressing


  • Incomplete penetration of cortex
  • Penetration of posterior cortex


  • Infection
  • Compartment syndrome
  • 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.[2]
    • Potassium is often elevated due to hemolysis
  • CANNOT use IO blood for CBC
    • WBCs are higher and platelet counts are lower[2]

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[3]
    • RSI medications can be given through IO with the same efficacy[4]
  • Same doses as IV meds
  • Follow with flush
  • Drips or IV fluids should be given with pressure bag or infusion pump

See Also


  1. Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.
  2. 2.0 2.1 Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.
  3. Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.
  4. Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]