Intraosseous Access

Aka: Intraosseous Access, Intraosseous Infusion, Intraosseous Cannulation, IO Line

1. See Also
   1. Intravenous Access
   2. Central IV Access
   3. Peripheral IV Access
   4. Ultrasound-Guided Internal Jugular Vein Catheterization
   5. Ultrasound-Guided Antecubital Line
2. Indications
   1. Emergent vascular access
   2. Allows for delivery of most fluids and medications (including Vasopressors), EXCEPT bicarbonate
3. Mechanism
   1. Entry into marrow cavity
   2. Allows rapid delivery into central access
   3. Marrow cavity entered most easily 6 years and younger
4. Preparation: Intraosseous Needles (e.g. EZ IO)
   1. Pediatric (15 gauge, 1.5 cm long, Red EZ-IO)
      1. Indicated for children under 40 kg
   2. Adult (15 gauge, 2.5 cm long, Blue EZ-IO)
      1. Indicated for children over 40 kg and non-obese adults
      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
         1. Humerus intraosseous
         2. Proximal Tibial intraossous if the tibial tuberosity is not palpable
   4. Images
      1. 
   5. References
      1. Kehrl (2016) Am J Emerg Med 34(9):1831-4 +PMID: 27344097 [PubMed]
5. Preparation: Sites
   1. Medial proximal tibia medial to tibial tuberosity (standard IO site)
      1. Landmark: 2-3 cm below and medial to tibial tuberosity
      2. Insert at flat anteromedial tibial surface
      3. Externally rotate hip to avoid injury to anterior tibial artery
   2. 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
   3. Proximal Shoulder at greater tubercle (greater tuberosity)
      1. Shoulder adducted and wrist supinated
      2. Needle inserted into anterolateral Shoulder at 90 degrees into greater tubercle
   4. Distal femur (neonate only)
      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
6. Preparation: Patient comfort
   1. Indications for pre-medication
      1. Awake, alert children
   2. Options
      1. Pre-anesthetize the skin with Local Lidocaine injection
      2. Consider Intranasal Fentanyl 1.5 to 2 mcg/kg
7. Technique: Insertion (EZ-IO)
   1. Identify landmarks for selected insertion site
   2. Prepare site (e.g. betadine or hibiclens)
   3. 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
   4. Attach needle driver
      1. Gently drive IO needle until bevel is at skin surface
   5. Stabilize needle and remove driver and stylet
   6. 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 cc Normal Saline
   7. 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
   8. Remove IO within 24 hours
8. 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
9. Complications (<1% of patients)
   1. Tibial Fracture
   2. Anterior tibial artery injury (risk of foot necrosis)
   3. Compartment Syndrome
   4. Skin necrosis
   5. Osteomyelitis
10. 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]
11. Resources
    1. Vidacare EZ-IO insertion video
       1. http://www.youtube.com/watch?v=GWmzVEqWQYg
12. References
    1. Claudius, Behar, Chang and Santillanes in Herbert (2016) EM:Rap 16(4): 3-4