11/13/24, 7\:20 PM Guide | Intraosseous (IO) access
Intraosseous (IO) access
Table of contents
Introduction
This intraosseous (IO) access guide provides a step-by-step approach to gaining intraosseous access in an OSCE setting.
This guide will cover the EZ-IO® device, which is commonly used in clinical settings. However, other types of IO access devices
exist, and it is important to follow local guidelines.
Figure 1. The EZ-IO® driver device
Intraosseous access
Intravenous cannulation can be challenging in certain situations, such as hypothermia, hypovolaemia, obesity and
environmental factors (e.g. poor lighting, limited patient access). Delays in achieving vascular access can result in delayed
patient management.
Intraosseous access (IO access) involves inserting a catheter into the medullary space of a long bone, providing access to the
systemic vasculature. Like intravenous access, IO medications can bypass
bioavailability.
Indications
Indications for establishing IO access include\:
Failure to gain intravenous access and urgent vascular access required
Cardiac arrest situations where IV access is not feasible or IV access has failed (common in pre-hospital practice)
Contraindications
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Relative contraindications to establishing IO access include\:
Inability to accurately identify landmarks at the chosen anatomical site
Long bone fracture
Vascular injury to the extremity
Previous orthopaedic procedure (e.g. prosthetic knee when selecting the proximal tibia site) or previous intraosseous
attempt at that site in the previous 24 hours
Overlying skin infection
Gather equipment
Collect the equipment required for the procedure and place it within reach, ensuring that all the items are clearly visible\:
Clean procedure tray (unlikely to be available in pre-hospital settings)
EZ-IO® driver
IO needles\: pink (15mm), blue (25mm) or yellow (45mm)
EZ-IO® stabilisation device*
IO extension set*
Non-sterile gloves
Alcohol swab (2% chlorhexidine gluconate in 70% isopropyl)
10ml Luer-Lok™ syringe
Normal saline 0.9% (10ml) or pre-
Sharps bin
If carrying out this procedure on a conscious patient\: local anaesthetic to
*This equipment is included in each EZ-IO® needle kit (Figure 2). The needle kit may also contain a red needle safety device.
Gather equipment
If IO access is being established for a
It is also useful to incorporate a three-way stopcock between the giving set and IO extension set to allow for the injection of
additional medications if required (e.g. adrenaline or amiodarone in cardiac arrest).
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Figure 2. An EZ-IO needle kit
Introduction
Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE if appropriate.
Note\: IO access is typically performed on critically unwell patients who are unconscious. However, carrying out the following
steps is good practice. IO access can also be gained on a conscious patient, local anaesthetic should be used as a
the needle is inserted (follow local guidelines).
Introduce yourself to the patient, including your name and role.
Con
Brie
“ I n e e d t o p e r f o r m i n t r a o s s e o u s c a n n u l a t i o n ,
w h i c h i n v o l v e s p l a c i n g a n e e d l e i n t o y o u r b o n e m a r r o w s o w e c a n d e l i v e r m e d i c a t i o n s . Y o u m a y e x p e r i e n c e a s m a l l s h a r p p a i n
a s t h e n e e d l e i s i n s e r t e d .
”
Gain consent to proceed with intraosseous access.
Check if the patient has any allergies (e.g. latex, adhesive).
Adequately expose the patient’s arms and legs as appropriate to landmark your chosen insertion site.
IO insertion sites
Insertion sites for the EZ-IO® include\:
Proximal humerus
Proximal tibia
Distal femur (paediatric)
Distal tibia (paediatric)
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Preparation
1. Don gloves (if not already wearing some).
2. Choose an appropriate needle size based on weight, intended insertion site and patient characteristics. The aim is for
the 5mm marker (the
the bone b e f o r e operating the driver.
15 mm/pink (weight 3 - 39kg)\: paediatric
25 mm/blue (weight ≥ 3kg)\: paediatric and adults
45mm/yellow (weight ≥ 40kg)\: adults, proximal humerus insertion, excessive tissue over the insertion site
3. Open the needle pack and place the contents on a sterile
4. Prepare the
carrying out IO access on a conscious patient, prepare a local anaesthetic
5. Prime the EZ-IO® extension tubing with your
aspirate once the cannula is inserted).
6. Identify your chosen insertion site using anatomical landmarks (these are described below).
Choosing an insertion site
Proximal humerus
The proximal humerus IO insertion site is located 1-2cm above the surgical neck of the humerus. To identify the insertion site\:
1. Place the patient's hand over the abdomen (elbow adducted and humerus internally rotated). Place your palm on the
patient’s shoulder anteriorly. The area that feels like a “ball” under your palm is the general target area. You should be able to
feel this ball, even on obese patients, by pressing deeply.
2. Place the ulnar aspect of your hand vertically over the axilla. Place the ulnar aspect of your other hand along the midline of
the upper arm laterally.
3. Place your thumbs together over the arm. This identi
4. Palpate deeply up the humerus to the surgical neck. This may feel like a golf ball on a tee- the spot where the “ball” meets
the “tee” is the surgical neck. The insertion site is 1 to 2cm above the surgical neck, on the most prominent aspect of the greater
tubercle.
5. The needle tip is inserted at a 45-degree angle to the anterior plane and posteromedial.
Advantages
Higher
Easily accessed from the head if the clinician is in the airway management position
Disadvantages
It can be dislodged and/or deformed if the arm is abducted and externally rotated
In cardiac arrest situations, the area around the torso and head is generally a hive of activity, and the humeral head site may
not be as easily accessible
Proximal tibia
The proximal tibia IO insertion site is approximately 2cm medial to the tibial tuberosity, or 3 cm below the patella and
approximately 2cm medially, along the
Identify the insertion site with the leg extended.
When using this site, avoiding the epiphyseal growth plate is important. This can be done by correctly landmarking the site.
Advantages
Higher
The patient’s legs are generally more accessible in cardiac arrest, allowing more space to perform the procedure
Disadvantages
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Unable to be used if vasculature compromised proximally (e.g. suspected fracture/fractured femur/pelvis)
Tibias may not be accessible in those patients entrapped pre-hospital
Paediatric site selection
IO access in children is more challenging as the bone structure is less rigid. In smaller infants, the needle can be inserted by
hand (and not using the driver) as it is easy to overshoot the medullary space accidentally. Always check and follow local
clinical practice guidelines.
Several sites exist for IO access in children\:
Proximal humerus\: similar to adults
Proximal tibia\: 1cm medial to the tibial tuberosity or just below the patella (approximately 1cm) along the
tibia, pinching the tibia between your
Distal femur\: 1cm proximal to the superior border of the patella and approximately 1-2cm medial to the midline
Distal tibia\: 1-2cm proximal to the most prominent aspect of the medial malleolus; the insertion site should be the
aspect of the bone
Insert the needle
1. Clean the insertion site with a chlorhexidine wipe.
2. Attach the needle to the driver.
3. Without operating the driver, manually press the needle and driver into the skin at the chosen site until it meets the bone. If
the
If the 5mm marker is not visible, do not proceed. Withdraw the needle, and choose an appropriate needle size.
Figure 3. The 5mm line on an EZ-IO needle
4. With gentle downward pressure on the driver, press the trigger to advance the needle.
5. Once the needle advances and you feel a “pop” or loss of resistance, you are in the correct space. Advance a little more to
ensure the catheter is fully in place. Take care not to advance beyond this space. It is possible to over-penetrate the medullary
space and enter the cortex on the opposite side.
6. Stabilise the hub and detach the driver; the stylet twists out of the hub (Figure 4) and should be disposed of in an appropriate
sharps bin.
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Figure 4. Removing the stylet.
7. Place the dressing over the hub and attach it to the skin. This must be done before connecting the extension tubing, as it
does not
Flush the catheter
1. Attach the extension tubing and open the clamp.
2. Aspirate the syringe to check for bone marrow (this may not always be present) and then
Adults\: 5 - 10ml
Children\: 2.5 - 5ml
3. There may be some resistance initially as the
Conscious patients
Flushing an intraosseous catheter can be painful for conscious patients. In conscious patients, administering a local
anaesthetic (e.g. lidocaine) through the IO catheter can reduce pain. However, local anaesthetic may not be available in all
settings - check and follow local guidelines.
To complete the procedure...
Dispose of your PPE and other clinical waste into an appropriate clinical waste bin.
Wash your hands.
Document the details of the procedure, including\:
The patient’s details\: full name, date of birth and unique identi
The date and time that IO access was performed
The indication for gaining IO access
The type of needle used
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The anatomical insertion site
The volume and type of
Your name, grade and contact details
Removing an IO catheter
To remove an IO catheter once it has been inserted, you will need the following\:
Gloves
A 10ml Luer-Lok™ syringe
Clean dressing
Sharps bin
Removal procedure
1. Don gloves (if not already wearing some).
2. Remove the extension tubing and dressing from the catheter hub
3. Attach the syringe to the IO catheter.
4. Maintaining the same alignment as the IO hub, twist the syringe and catheter clockwise while pulling straight out. Do not
rock or bend during IO needle removal.
5. Place the catheter and the syringe into a sharps container as a single unit.
6. Apply a clean dressing to the site.
Reviewer
Dr Jason van der Velde
Prehospital Emergency Medicine and Critical Care Retrieval Physician
References
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2023. P r e-h o s p i t A l R A n d o m i s e d t r i a l o f M E D I C a t i o n r o u t e i n o u t-o f -h o s p i t a l c a r d i a c a r r e s t ( P A R A M E D I C- 3 ) . Available
2. Garabon, J.J.W., Gunz, A.C., Ali, A. and Lim, R., 2022. EMS Use and Success Rates of Intraosseous Infusion for Pediatric
Resuscitations\: A Large Regional Health System Experience.
3. Pasley, J., Miller, C.H.T., DuBose, J.J., Shackelford, S.A., Fang, R., Boswell, K., Halcome, C., Casey, J., Cotter, M., Matsuura, M., Relph,
N., Tarmey, N.T. and Stein, D.M., 2015. Intraosseous infusion rates under high pressure\: a cadaveric comparison of anatomic sites.
T h e j o u r n a l o f t r a u m a a n d a c u t e c a r e s u r ge r y , [online] 78(2), pp.295–299.
4. Reades, R., Studnek, J.R., Vandeventer, S. and Garrett, J., 2011. Intraosseous versus intravenous vascular access during out-of-
hospital cardiac arrest\: a randomized controlled trial. A n n a l s o f e m e r g e n c y m e d i c i n e , [online] 58(6), pp.509–516.
5. Reid, C., 2018. H u m e r a l I n t r a o s s e o u s – S t a y I n & S t a y S t r a i g h t . [online] Online. Available from\: [LINK]
6. Soar, J., Böttiger, B.W., Carli, P., Couper, K., Deakin, C.D., Djärv, T., Lott, C., Olasveengen, T., Paal, P., Pellis, T., Perkins, G.D., Sandroni,
C. and Nolan, J.P., 2021. European Resuscitation Council Guidelines 2021\: Adult advanced life support. [online]
7. Telefex Medical, 2016. A r r o w E Z-I O I n t r a o s s e o u s V a s c u l a r A c c e s s S y s t e m P o c k e t G u i d e . [online] Available from\: [LINK]
Source\: geekymedics.com
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