Intraosseous access
Indications
- 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)
Contraindications
- osteoporosis
- osteogenesis imperfecta
- fractured bone
- recent IO infusion in same bone
- insertion at site of cellulitis, infection, or burn
Equipment
- 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)
- EZ-IO drill
- Appropriate IO needle with extension set
- chloraprep
- NS flush
- Lidocaine (2% lidocaine without epi - cardiac lidocaine)
Site Selection (for EZ-IO system)
- 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)
EZ-IO Needle selection (based on weight of patient)
- Pink 15mm (3-39kg)
- Blue 25mm (40kg and above)
- Yellow 45mm (excessive tissue)
Procedure
- identify landmarks
- prep 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
- attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
- aspirate blood/marrow to confirm placement
- flush saline through extension set to ensure good flow
- if pt is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful)
- apply dressing
- 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.
Complications
- incomplete penetration of cortex
- penetration of posterior cortex
- pain
- infection
- compartment syndrome
- growth plate damage
- fat embolism
Labs?
- Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
- CANNOT use IO blood for CBC
IO Medications
- Any medication that can be given in peripheral IV can be given through IO
- Same doses as IV meds
- Follow with flush