Intraosseous (IO) access

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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



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

Site Selection

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

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

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


  • Identify landmarks
  • 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 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 manuacturer'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 dressing


  • 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.

(IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved[2])


  • 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.[3]
    • Potassium is often elevated due to hemolysis
  • CANNOT use IO blood for CBC
    • WBCs are higher and platelet counts are lower[3]

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[4]
    • RSI medications can be given through IO with the same efficacy[5]
  • 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 [6]
  • Successful CTA PE protocol reported [7]
  • Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure) [8]

See Also


  2. Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.
  3. 3.0 3.1 Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.
  4. 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.
  5. 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]
  6. Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386
  7. Ahrens, et al. Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report. Journal of Emergency Medicine. 2013; 45 (2): 182-184
  8. Miller, et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4) 240-241.