Intraosseous Access

Aka: Intraosseous Access, Intraosseous Infusion, Intraosseous Cannulation, Intraosseous Line, IO Line, IO Access, Intraosseous Cathether Placement, EZ-IO

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II. Indications

  1. Emergent Vascular Access
  2. Allows for delivery of most fluids and medications (including Vasopressors), EXCEPT bicarbonate

III. Mechanism

  1. Entry into marrow cavity
  2. Allows rapid delivery into central access
  3. Marrow cavity entered most easily 6 years and younger

IV. Preparation: Intraosseous Needles (e.g. EZ IO)

  1. Infant (15 gauge, 1.5 cm long, Red EZ-IO)
    1. Indicated for children <3 kg
  2. Standard (15 gauge, 2.5 cm long, Blue EZ-IO)
    1. Indicated for children 3-39 kg, up to non-obese adults without significant excess soft-tissue
    2. Even in obese adults, may use for proximal tibial intraosseous (as long as tibial tuberosity is palpable)
  3. Long (15 gauge, 4.5 cm long, Yellow EZ-IO)
    1. Indicated for large, obese adults or significant excess soft tissue
      1. Humerus intraosseous
      2. Proximal Tibial intraossous if the tibial tuberosity is not palpable
  4. Images
    1. cvIO.png
  5. References
    1. Kehrl (2016) Am J Emerg Med 34(9):1831-4 +PMID: 27344097 [PubMed]

V. Preparation: Sites

  1. Images
    1. ioSites.jpg
  2. Medial proximal tibia medial to tibial tuberosity (standard IO site)
    1. Landmark: 2-3 cm below and medial to tibial tuberosity
      1. Two finger breadths below the lower Patellar pole in an adult (1 finger breadth in a child)
    2. Insert at flat anteromedial tibial surface (flat plane is oriented 45 degrees medially)
    3. Externally rotate hip to avoid injury to anterior tibial artery
  3. Medial distal tibia proximal to medial malleolus
    1. Hip abducted and externally rotated with knee flexed
    2. Landmark: 2-3 cm proximal to medial malleolus on mid-point of flat medial tibia surface
    3. Insert IO perpendicular to flat tibia surface
      1. Angle IO very slightly proximally (toward knee) to avoid Epiphyseal Plate in children
  4. Proximal Shoulder at greater tubercle (greater tuberosity)
    1. Advantages
      1. Highest potential IO flow rates due to larger marrow space (up to 5 L/hour)
      2. Rapid entry to circulation (3 seconds to central circulation)
      3. Less pain with insertion and infusion
      4. No reported Compartment Syndrome complications
    2. Disadvantages
      1. Highest risk for IO displacement
    3. Positioning
      1. Shoulder internally rotated (must be kept in this position while IO in place to prevent displacement)
      2. Elbow flexed to 90 degrees
      3. Hand should rest on the Abdomen over the Umbilicus
      4. Arm abducted against the body
    4. Identify IO insertions site at the greater tubercle
      1. Place ulnar aspect of one hand, oriented vertically over the axilla
      2. Place the other hand, oriented vertically over the lateral Shoulder
      3. Each thumb applied to the vertical midline between the 2 hands
        1. Palpate the line up and down to identify the humeral surgical neck where meeting the head
        2. Insertion point lies 1-2 cm (1 fingerbreadth) superior/proximal to the surgical neck
      4. Alternatively, palpate the bicipital groove at the biceps tendon insertion (overlying humeral head)
        1. Bicipital groove may be easily palpated on internal and external rotation of the Shoulder
        2. Insertion point lies 1-2 cm (1 fingerbreadth) lateral to the biceps tendon insertion
    5. Needle inserted into anterolateral Shoulder into greater tubercle
      1. Use a longer IO needle (yellow in an adult)
      2. Direct needle posteromedially (directly into largest marrow space and avoids Growth Plate)
        1. Directed 45 degree angle to the anterior plane
        2. Directed 45 degrees angle to the horizontal plane
      3. Insertion site landmarks
        1. Insert at 2 cm above the surgical neck of the Humerus
        2. Insert at 2 cm lateral to the bicipital tendon insertion
  5. Distal femur (child only <= age 6 years)
    1. Palpate the flat portion of the anterior distal femur, several centimeters superior to the knee
    2. Angle 75-80 degrees towards proximal femur, away from knee Physis
    3. Increase the needle size by 1 to ensure adequate depth

VI. Preparation: Patient comfort

  1. Background
    1. Insertion of IO is similar to IV Access pain
    2. Pain with IO is primarily with the infusion (see below)
  2. Indications for pre-medication
    1. Awake, alert children
  3. Options
    1. Pre-anesthetize the skin with Local Lidocaine injection
    2. Consider Intranasal Fentanyl 1.5 to 2 mcg/kg

VII. Technique: Insertion (EZ-IO)

  1. Identify landmarks for selected insertion site
  2. Have intravenous Lidocaine 2% and saline flush ready
    1. Flush the tubing with the Lidocaine solution (see dosing below)
  3. Prepare site (e.g. Betadine or Chlorhexidine)
    1. Chlorhexidine should dry for at least 30 seconds before use (Betadine for at least 3 minutes)
  4. Insert needle at 90 degrees (perpendicular) to skin surface
    1. Insert needle through skin by hand until it contacts bone
    2. At least one black marker (5mm) should be visible above skin margin
    3. If no marker is visible, then use a larger needle instead
  5. Attach needle driver
    1. Gently drive IO needle until bevel is at skin surface
  6. Stabilize needle and remove driver and stylet
  7. Flush the catheter
    1. Anesthetize the site in awake patients prior to fluid or medication infusion
      1. Lidocaine 2% (20 mg/ml preservative free) delivered slowly through Intraosseous catheter
      2. Dose: 0.5 mg/kg up to maximum of 20-40 mg (1-2 ml) in adults of 2% Lidocaine
    2. Flush line with 10 ml Normal Saline
      1. Catheter should flush easily
      2. If high resistance to flow, catheter is likely malpositioned
  8. Stabilize and protect catheter to prevent dislodgement
    1. Consider stabilizing with gauze to either side of the catheter
    2. Some use the cut bottom of a cup to place over the IO site
  9. Apply a sterile dressing over the top of the catheter
    1. May use Tegaderm with a central hole if specialized dressing is not available
  10. Intravenous infusion
    1. Will require a pressure bag for infusion
  11. Remove IO within 24 hours
    1. Mark the insertion site with a patient wrist band, indicating time and date of insertion

VIII. Technique: Removal (EZ-IO)

  1. Remove attached catheter
  2. Attach sterile syringe via luer-lock
  3. Turn syringe in clockwise direction while gently pulling until EZ-IO is removed
  4. Apply sterile bandage

IX. Complications (<1% of patients)

  1. Tibial Fracture
  2. Anterior tibial artery injury (risk of foot necrosis)
  3. Compartment Syndrome
  4. Skin necrosis
  5. Osteomyelitis

X. Technique: Lab sample via Intraosseous Line

  1. Precautions
    1. Other methods are preferred
    2. Risk of aspirated bone spicules damaging lab analysis equipment
  2. Technique
    1. Blood aspirated from intraosseous and first 2 ml discarded
    2. May be run off i-Stat point of care machines
  3. Labs with unreliable IO results (Avoid)
    1. Complete Blood Count
      1. Unreliable for Hemoglobin, Hematocrit, Platelet Count, White Blood Cell Count and differential
    2. Blood Gas
      1. Unreliable for pH (except in acidosis), pCO2, pO2
    3. Serum Potassium
      1. IO source results in falsely elevated Serum Potassium (2 mEq/L higher than serum sample)
  4. Labs with reliable IO results (via i-Stat)
    1. Serum bicarbonate
    2. Base Excess
    3. Serum Sodium
    4. Serum Calcium
    5. Serum Glucose
  5. References
    1. Veldhoen (2014) Resuscitation 85(3): 359-63 [PubMed]

XI. Resources

  1. Vidacare EZ-IO insertion video
    1. http://www.youtube.com/watch?v=GWmzVEqWQYg
  2. Dornhofer (2023) Intraosseous Vascular Access, StatPearls
    1. https://www.ncbi.nlm.nih.gov/books/NBK554373/

XII. References

  1. Claudius, Behar, Chang and Santillanes in Herbert (2016) EM:Rap 16(4): 3-4

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