Intraosseous access

Indications

3 EZ-IO sizes

• Immediate vascular access required for administration of drugs/fluids
• Cardiac arrest, resuscitation when no other IV in place

15 Gauge IO sizes

Contraindications

• Osteoporosis
• Osteomyelitis
• Osteogenesis imperfecta
• Fractured bone
• Recent IO infusion in same bone
• Cellulitis, Infection, or Burn, at insertion site

Equipment

• EZ-IO drill (other products/brands available)
• Appropriate IO needle with extension set
• Chloraprep or alcohol swabs
• Saline Flush
• Lidocaine (2% lidocaine without epi)

Site Selection

• Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
• Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
• Proximal humerus (adults only, use yellow needle)
  • keep arm adducted and internally rotated (hand on bellybutton)
  • slide fingers up humerus until you feel a notch (surgical neck)
  • insert IO 1cm above surgical neck into the greater tubercle
  • immobilize arm or IO will displace (no abduction at shoulder)
• Distal Femur (generally only in infants and children)
• Pelvic ASIS

EZ-IO Needle selection (based on weight of patient)

• Pink 15mm (3-39kg)
• Blue 25mm (40kg and above)
• Yellow 45mm  (excessive tissue)

Procedure

• Identify landmarks
• Clean skin
• Place appropriate needle on drill and remove safety cap
• ADVANCE needle through skin to bone
• DRILL needle perpendicular into bone at site with gentle, constant pressure
• When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)
• Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
• Remove stylet (caution: stylet is extremely sharp - place in sharps container)
• Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
• Aspirate blood/marrow to confirm placement
• If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)
• Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
• Apply dressing

Removal

• Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
  • Can attach syringe via luer lock to act as handle
• Apply dressing.

(IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved)

Complications

• Compartment syndrome
• Incomplete penetration of cortex
• Penetration of posterior cortex
• Infection (cellulitis, osteomyelitis)
• Fracture
• Growth plate damage
• Fat embolism

Labs drawn via IO

• Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
  • There is not good correlation with Sodium, Potassium, CO₂, and calcium levels.
  • Potassium is often elevated due to hemolysis
• CANNOT use IO blood for CBC
  • WBCs are higher and platelet counts are lower

IO Medications

• Any medication that can be given in peripheral IV can be given through IO
  • Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line
  • RSI medications can be given through IO with the same efficacy
• Same doses as IV meds
• Follow with flush
• Drips or IV fluids should be given with pressure bag or infusion pump

IO and CT contrast

• Overall safe and effective
• Case reports with successful venous opacification in a trauma patient
• Successful CTA PE protocol reported
• Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure)

See Also

• Access options

References

Authors

Joe Rogers, Ann Huang, Daniel Ostermayer, Neil Young, Michael Holtz, Marissa Camilon, Ross Donaldson, Yos Yachivev, Hanno Davel