Introduction
Obtaining intravascular access in the emergency department is one of the most essential steps in managing critically ill patients. While it is a simple step for most patients, it can be the most challenging procedure during resuscitation. The pediatric population has more body fat, making it difficult to localize their veins. In addition, they have tiny peripheral veins that easily collapse in states of shock. On the other hand, in adults, patients who are obese, those who suffer from extensive burns, or are in shock challenge the clinician in obtaining vascular access [1].
Intraosseous (IO) access involves inserting a hollow needle through the cortex of the bone and into the medullary space. This allows clinicians to infuse fluids, medication, or almost anything that can be administered through the intravenous (IV) route and achieve the same desired effect as the IV route. The IO line is merely a bridging tool to buy the clinician time to obtain IV access. In most cases, IO access is a simple procedure, and clinicians should not hesitate to insert an IO line if peripheral IV access attempts fail.
IO lines can safely remain in place for up to 24 hours and are often a bridge to either IV or Central Venous line placement.
Indications
There are clear indications for IO access. Each of these indications highlights the critical role of IO lines in emergency medicine, providing a swift and effective solution for vascular access in life-threatening situations [3]. When IV access cannot be achieved, IO access is safe, reliable, and quick. It can be accomplished in 30 to 60 seconds and even faster with an IO gun. This is especially helpful in pediatric emergencies when time is critical.
Emergency intravascular access when other methods have failed
IO access is indicated when IV access is not achievable in critical situations, such as trauma, shock, or severe dehydration. In critically ill patients, a maximum of two failed attempts is generally considered sufficient to shift to IO access. The IO line provides a rapid and reliable alternative to IV lines for administering fluids, medications, or blood products directly into the vascular system via the bone marrow [4].
Cardiac arrest
During cardiac arrest, time is critical, and establishing vascular access can be challenging. IO access is often used to administer life-saving medications like epinephrine when IV access cannot be obtained quickly. It ensures the rapid delivery of drugs into circulation during resuscitation [5].
Obtaining blood for laboratory evaluation
IO access allows for the collection of blood samples for laboratory testing, including complete blood count, electrolytes, and blood gas analysis [6]. This is especially useful in emergency situations where traditional venipuncture is impractical or impossible.
Contraindications
Physicians should be aware of a couple of important complications. These contraindications emphasize the importance of careful site selection and patient evaluation before performing IO access to minimize complications and maximize the effectiveness of the procedure [1].
Fractured bone
A fracture at the intended site of IO access is an absolute contraindication. Using a fractured bone for IO infusion can result in extravasation of fluids and medications, potentially worsening the injury and causing further complications.
Infection or burn overlaying insertion site
Localized infection or burns at the insertion site pose a significant risk of introducing pathogens into the bone marrow, leading to osteomyelitis or systemic infection. These conditions are absolute contraindications for IO placement.
Prior use of the same bone for IO infusion
Repeated use of the same bone for IO access can damage the bone marrow and structure, increasing the risk of complications such as extravasation or impaired drug delivery. A different site should be chosen for subsequent IO insertions.
Osteoporosis and osteogenesis imperfecta
These conditions result in fragile bones, increasing the likelihood of fractures or other complications during needle insertion. Alternative access methods should be considered for patients with these conditions.
Administration of ultra-short-acting medications like adenosine (relative contraindication)
Medications like adenosine, which rely on rapid systemic distribution, may not be as effective when administered via IO access due to potential delayed uptake into circulation. This is a relative contraindication, depending on the clinical scenario.
Equipment and Patient Preparation
Equipment
IO Needle
- Ranges from 15-18 gauge needles
- Color coding is common:
- Pink (15 mm): For patients weighing 3–39 kg
- Blue (25 mm): For patients ≥3 kg and above
- Yellow (45 mm): For patients ≥40 kg, excessive tissue, or dense bone sites (e.g., proximal humerus or anterior superior iliac spine)
IO Devices (to facilitate insertion)
- Powered IO Drills (e.g., EZ-IO)
- Manual IO Drills (e.g., Cook IO Needle or Jamshidi-type needle)
Skin Disinfectants
- Chloraprep
- Alcohol swabs
- Optional: Povidine or Chlorhexidine
Syringe and Flush Materials
- Saline flush (crystalloid solution, e.g., normal saline or lactated Ringer’s)
- Intravenous tubing
Lidocaine 2% (without epinephrine)
- For topical and subcutaneous infiltration in awake patients, as they may experience pain during fluid infusion rather than needle insertion.
Additional Equipment
- Infusion pump (to regulate fluid delivery)
- Tape (for securing the IO line)
Patient Preparation
- Informed Consent
- Obtain informed consent by explaining the procedure, its benefits, and associated risks to the patient or their guardians. In emergency situations where consent cannot be obtained, implied consent applies.
- Site Selection
- Choose the most appropriate insertion site based on the clinical scenario. Common sites include:
- Humeral Head
- Proximal Tibia
- Medial Malleolus
- Sternum
- Distal Radius
- Distal Femur
- Anterior Superior Iliac Spine
- Note: The proximal tibia and humeral head are most commonly used during cardiac arrest as these locations do not interfere with other life-saving procedures like intubation [7].
- Choose the most appropriate insertion site based on the clinical scenario. Common sites include:
- Contraindication Assessment
- Ensure there are no contraindications (e.g., fractures, infections, burns, prior IO use at the same site, or certain bone conditions) at the intended site of insertion.
- Site Exposure
- Properly expose the selected insertion site to facilitate accurate placement and reduce the risk of contamination.
- Universal Precautions
- Apply universal precautions, such as wearing gloves at a minimum, to maintain aseptic conditions during the procedure.
Sites of IO insertion and some hints [8]
- Proximal Tibia
- 2 finger breadths below the tibial tuberosity (1-3 cm) on the medial, flat aspect of the tibia.
- Commonly used for ease of access, especially in emergencies.
- Distal Tibia
- Medial surface at the junction of the medial malleolus and the shaft of the tibia, posterior to the greater saphenous vein.
- Proximal Humerus (Adults only; use the yellow needle)
- Preparation:
- Keep the arm adducted and internally rotated (rest the patient’s hand on their bellybutton).
- Slide fingers up the humerus until you feel the notch (surgical neck).
- Insertion:
- Insert the IO needle 1 cm above the surgical neck into the greater tubercle.
- Immobilize the arm to prevent displacement of the IO line (avoid shoulder abduction).
- Preparation:
- Distal Femur
- Primarily used in infants and children due to easier bone access and growth plate considerations.
- Pelvic Anterior Superior Iliac Spine (ASIS)
- An alternative site, especially when lower extremity or upper extremity sites are unavailable.
- Sternum
- Provides the highest flow rate of any location, making it suitable for rapid infusions during critical situations.
Procedure Steps
- Preparation
- Identify the designated site using a sterile gloved finger.
- Disinfect the overlying skin using appropriate antiseptic (e.g., chlorhexidine).
- Administer local anesthetic if the patient is awake.
- Ensure the stylet is properly positioned on the needle prior to insertion.
- Prepare necessary equipment, including a 20 ml saline syringe, IV tubing, tape, medications, fluids, and infusion pump.
- Needle Insertion
- Insert the needle perpendicularly through the skin down to the bone.
- Use an IO drill or manually twist the needle clockwise with firm, gentle pressure until a “give” is felt (loss of resistance), indicating entry into the marrow.
- Ensure the needle locks into place.
- Confirmation of Placement
- The needle should stand upright without additional support if properly positioned.
- Remove the stylet and attach a syringe.
- Aspirate to confirm the presence of marrow or blood (not always visible).
- Gently flush the line with saline while observing for swelling at or around the insertion site.
- Troubleshooting
- If swelling occurs or the test injection fails, remove the IO needle and repeat the procedure on a different site.
- Securing and Using the IO Line
- If Io works properly, stabilize the needle using tape or gauze padding as necessary.
- Attach IV tubing to the needle hub.
- Begin infusion of fluids, blood products, or medications.
- If the patient is awake and experiences pain during infusion, administer lidocaine through the IO line for analgesia [2].
Complications [9]
Extravasation of Fluid
Occurs when fluid or medication leaks into surrounding soft tissues instead of the bone marrow cavity. This can cause localized swelling, tissue damage, and discomfort. Proper placement and observation for swelling during infusion are essential to avoid this complication.
Compartment Syndrome
Results from increased pressure within a muscle compartment due to extravasation of fluid. It can compromise blood flow, leading to tissue ischemia and potential necrosis. Immediate recognition and corrective action are necessary to prevent long-term damage [10].
Bone Fracture
More common in patients with pre-existing bone disorders, such as osteoporosis or osteogenesis imperfecta. Improper needle insertion technique can increase the risk of fracturing the bone at the insertion site. Physicians should be careful when inserting IO lines in small children because too much pressure during drilling may cause fractures.
Osteomyelitis
A rare but serious complication involving infection of the bone and marrow. This risk increases if aseptic technique is not followed or if there is a pre-existing infection near the insertion site.
Preventative Measures:
- Use strict aseptic technique to minimize infection risks.
- Properly assess the patient’s bone health and contraindications before insertion.
- Monitor the insertion site for early signs of complications, such as swelling or pain, during and after infusion
Hints and Pitfalls
Purpose and Time Limit
- IO access is a bridging tool used to buy time for obtaining peripheral or central IV access.
- IO needles should not remain in place for more than 24 hours, as the risk of complications increases significantly after that time frame.
Site and Device Selection
- Always use an uninjured limb for IO placement; if no uninjured limb is available, the sternum is preferred.
- An IO drill or gun is recommended over manual insertion for consistent and reliable placement.
- Needle selection must be appropriate for the selected site and the marrow cavity to ensure proper access.
Needle Placement and Security
- IO needle displacement can sometimes occur, especially in pediatric patients with soft bones; this can be mitigated by securing the needle to the skin properly.
- The anterior superior iliac spine may be considered as an alternative site in cases of soft bone structures.
Medication and Dosage
- Any medication that can be administered via IV access can also be given through IO access without dose adjustment, as the bioequivalence between IO and IV routes is similar. [11,12]
Laboratory Sampling
- Lab tests with good correlation from IO samples include hemoglobin/hematocrit, chloride, glucose, urea, creatinine, and albumin.
- Other lab values, such as WBC, platelets, serum CO2, sodium, potassium, and calcium, may not correlate well with venous samples. [13]
Special Patient Groups
Pediatrics
- Challenges: In pediatric patients, the bones can sometimes be too soft, which increases the risk of needle displacement even when placed correctly.
- Recommendation: To mitigate this risk, consider using the anterior superior iliac spine as an alternative site. This site may provide a more stable placement in cases where traditional sites like the tibia are less effective.
Geriatrics
- Challenges: Older adults often have pre-existing bone disorders such as osteoporosis, which make their bones more fragile.
- Risks: IO insertion in such patients can lead to fractures, especially if not performed with careful technique and appropriate needle selection.
- Recommendation: Perform a thorough assessment of bone health and use alternative vascular access methods if significant bone fragility is present.
Pregnant Patients
- Considerations: There are no contraindications for IO insertion in pregnant women. This makes IO access a viable option during emergencies where quick vascular access is necessary.
- Precautions: Ensure that the chosen site does not interfere with obstetric care and consider patient positioning to maintain comfort and safety during the procedure.
Authors
Yousif Al-Khafaji
Chief Emergency Medicine Resident - Tawam Hospital, Al Ain, UAE
Mustak Dukandar
Tawam Hospital Emergency Department
Listen to the chapter
References
- Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Car-Elsevier (2017), chapter 25
- ATLS Student course manual Tenth Edition (2018). Appendix G, 351
- Phillips L, Brown L, Campbell T, et al. Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various healthcare settings: a consensus paper. J Emerg Nurs. 2010;36(6):551-556. doi:10.1016/j.jen.2010.09.001
- Oksan D, Ayfer K. Powered intraosseous device (EZ-IO) for critically ill patients. Indian Pediatr. 2013;50(7):689-691. doi:10.1007/s13312-013-0192-z
- Leidel BA, Kirchhoff C, Bogner V, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009;3(1):24. Published 2009 Oct 8. doi:10.1186/1754-9493-3-24
- Tallman CI, Darracq M, Young M. Analysis of intraosseous blood samples using an EPOC point of care analyzer during resuscitation. Am J Emerg Med. 2017;35(3):499-501. doi:10.1016/j.ajem.2016.12.005
- Wampler D, Schwartz D, Shumaker J, Bolleter S, Beckett R, Manifold C. Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients. Am J Emerg Med. 2012;30(7):1095-1099. doi:10.1016/j.ajem.2011.07.010
- Day MW. Intraosseous devices for intravascular access in adult trauma patients. Crit Care Nurse. 2011;31(2):76-90. doi:10.4037/ccn2011615
- ACLS provider Manual Supplementary Material (2016). Intraosseous Access, 57-61
- Vidal R, Kissoon N, Gayle M. Compartment syndrome following intraosseous infusion. Pediatrics. 1993;91(6):1201-1202.
- Faga, M., & Wolfe, B. (2016). Vascular access in hospitalized patients. Hospital Medicine Clinics, 5(1), 1-16.
- Von Hoff, D.D., Kuhn, J.G., Burris, H.A. 3rd, & Miller, L.J. (2008). Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med, 26, 31-38
- Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260.
FOAM and Further Reading
- Arrow EZ Intraosseous Insertion Proximal Humerus Video: https://www.youtube.com/watch?v=o4A-T4A80uQ
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
