Intraosseous (IO) Line/Access

by Keith A. Raymond


Peripheral Intravenous (IV) cannulation is a nursing skill. Few countries throughout the world require physicians to perform this procedure on a regular basis. Mastery of technique, understanding nuances and anatomy, and daily performance are required to maintain this skill. Therefore, if a nurse reports that he is unable to obtain IV access, and it is required urgently, establishing an IV access or intraosseous (IO) line should be considered to avoid delay.

Following medicine delivery and fluid resuscitation utilizing an IO line, transition to peripheral intravenous or central intravenous access is easier to achieve, and the intraosseous line may be discontinued.

Intraosseous lines can safely remain in place for up to 24 hours and are often a bridge to either IV or Central Venous line placement.

Intraosseous Line Access and Procedure

Emergency Indications

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. Almost anything that can be given IV such as medications, fluids, blood products and continuous infusions of catecholamines (epinephrine, norepinephrine, and dopamine).


  • Absolute:
    • fracture or crush injuries near or proximal to the access site,
    • fragile bone conditions such as Osteogenesis Imperfecta,
    • previous attempts in the same bone,
    • the presence of infection in or on the overlying tissue of the bone,
    • demineralized or immature bone.
  • Relative:
    • IV access can be obtained readily.
    • Use for only ultra short-acting medications such as Adenosine.

Equipment and Patient Preparation


  • gloves,
  • skin disinfectant (Povidine or Chlorhexidine and Alcohol Swabs),
  • 16-18 gauge IO or Jamshidi-type needle,
  • tape,
  • syringe,
  • isotonic crystalloid solution, and intravenous tubing.
  • Optional:
    • IO drill or gun, Infusion pump,
    • 2% Lidocaine for topical and subcutaneous infiltration (awake patients tend to report pain with fluid infusion rather than insertion).
  • NOTE: Color coding of IO needles is common
    • Pink (15 mm) for patients 3 – 39 kg,
    • Blue (25 mm) for patients 40 kg and greater,
    • Yellow (45 mm) for large patients or dense bone sites such as proximal humerus or anterior superior iliac spine.

Patient Preparation

  • Obtain informed consent or implied, following procedure discussion, risks, and benefits.
  • Select site: humeral head, proximal tibia, medial malleolus, sternum, distal radius, distal femur, and/or anterior superior iliac spine.
  • Proximal Tibia and Humeral Head are most commonly used during arrests as placement does not interfere with intubation or other activities.
  • Always apply universal precautions (gloves as a minimum) to the procedural list.


  1. Once the patient is prepared, identify the designated site with a sterile gloved finger.
  2. Disinfect overlying skin, and provide local anesthetic as desired.
  3. Be sure the stylet is in place on the needle prior to insertion.
  4. Have a 20 ml Saline syringe flush, IV tubing, tape, medications, fluids, and pump prepared, as required.
  5. Place the needle through the skin, perpendicular and down to the bone.
  6. Activate the IO drill or gun until the IO needle anchors in place, OR manually TWIST the needle clockwise (don’t push) with gentle firm pressure until the bone gives (loss of resistance technique) and the needle locks into place.
  7. The bone give is an indication the needle has passed through cortical bone into the marrow.
  8. If properly positioned, the needle will stand without support and be fixed in place.
    • Remove the stylet and attach the syringe and aspirate, marrow and blood confirms placement but may not always appear.
  9. Gently flush saline through the needle and watch the insertion site for swelling.
  10. If the test injection is unsuccessful or swelling is seen on the opposite side of the bone, repeat the above procedure with a new IO needle on another bone.
  11. If successful, stabilize the needle with the tape; gauze padding may be used as desired.
  12. Attach the IV tubing to the needle hub and infuse fluids, blood products, or medications.

Video – Intraosseous Needle Line Insertion

Video – Intraosseous Needle Line Insertion in A Real Patient

Post Procedure Care

  • All medications administered should be followed by a 20 ml Saline flush.
  • A three-way stopcock should be attached to the IO line if it is not in active use.
  • All IO needles should be removed within 24 hours or as soon as an IV or Central line is placed.
  • Be vigilant during infusions for tissue swelling or needle displacement.

Hints and Pitfalls

  • Always used an uninjured limb; if none available, the sternum is best.
  • An IO drill or gun should be used preferentially to manual insertion
  • In pediatric patients, if the bone is too soft, needle displacement is inevitable despite proper placement. Select anterior superior iliac spine.
  • IO needle selection should be consistent with the site and marrow cavity.
  • IO needle displacement sometimes can be avoided by properly securing it to the skin.


  • Bone fracture
  • Compartment Syndrome
  • Extravasation of Drugs
  • Osteomyelitis

References and Further Reading

  • ACLS Provider Manual Supplementary Material (2011). Intraosseous Access, 64-67
  • Arrow EZ Intraosseous Insertion Proximal Humerus Video:
  • Leidel, B.A., Kirchhoff, C., Bogner, V., Stegmaier, J., Mutschler, W., Kanz, KG., & Braunstein, V. (2009). Is the intraosseous 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 Safety in Surgery, 3(1), 24-31. doi: 10.1186/1754-9493-3-24

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