Intraosseous (IO) Placement/Infusion

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  • immediate access required for administration of drugs/fluids
  • cardiac arrest, resuscitaion when no other IV in place
  • Do not use IO for more than 24 h (ideally place the IO for immediate resus needs, then establish peripheral or central lines as needed)


  • osteoporosis
  • osteogenesis imperfecta
  • fractured bone
  • recent IO infusion in same bone
  • insertion at site of cellulitis, infection, or burn


  • multiple different types of IO needles and products available
  • EZ-IO device used at HUCLA (equipment stored in green box in medicine room in adult ED, or in cabinets of room 4 in peds ED)
  1. EZ-IO drill
  2. Appropriate IO needle with extension set
  3. chloraprep
  4. NS flush
  5. Lidocaine (2% lidocaine without epi - cardiac lidocaine)

Site Selection (for EZ-IO system)

  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. 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. prep 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 pt is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful)
  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
  • pain
  • infection
  • compartment syndrome
  • growth plate damage
  • fat embolism


  • Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
  • CANNOT use IO blood for CBC
  • Chem 7 generally accurate although K often elevated due to hemolysis

IO Medications

  • Any medication that can be given in peripheral IV can be given through IO
  • Same doses as IV meds
  • Follow with flush
  • drips or IVF should be given with pressure bag or infusion pump