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Just Screw It

Ah yes IO’s. In my opinion IO (Intraosseous) access is a very underutilized option despite the numerous positive studies by reputable sources, the ease and speed of placement, and the fact that any drug that is given IV can be given via the IO route.

EZ-IO Kit common in most ERs

I have worked at numerous trauma facilities and the use of IO kits varied heavily at each. Some rarely, if ever used IOs and would opt to achieve a central line instead (increasing time to drug administration). Some did not let nurses perform IO insertion and only doctors were permitted to do so (IO insertion is well within the scope of an RN and paramedic but facilities can change protocols), and some inserted an IO into any patient that traditional access was attempted, failed and the patient needed treatment now. The latter is how it should be...EVERYWHERE.

The IO is not as scary as it looks, and when done properly is actually reported to be less painful than an ABG or NG tube placement. The main purpose of an IO is to gain quick and effective vascular access in an urgent situation. The IO needle is inserted into the non-collapsible venous plexus of the bone marrow resulting in a safe, reliable and rapid access route.

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

They can be performed on any age group and inserted in 4 landmarks, the Proximal humerus, the proximal tibia, the distal tibia, and in pediatrics only, the distal femur. The proximal humerus is the best location if possible as it has the highest flow rate (5L/hr), is the least painful and delivers drugs to the central circulation in just 2 seconds. Unfortunately, this location is difficult during a code due to CPR and the number of doctors in your way. Thus, the most common spot is the proximal tibia which also happens to be the easiest landmark to find. If your patient is conscious however, consider the humerus.

The EZ-IO needles are all 15G and vary in length by weight /common sense. They are color coded but have no correlation to gauge size.

EZ-IO needle sizes

15mm Pink: 3-39kg

25mm Blue: >3kg

45mm Yellow: >40kg (for the fluffy/buff patients)

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

Proximal Humerus Identification and Insertion:


Place the patient’s hand over the abdomen (elbow adducted and humerus internally rotated)

Place your palm on the patient’s shoulder anteriorly

  • The area that feels like a “ball” under your palm is the general target area

  • You should be able to feel this ball, even on obese patients, by pushing deeply

Place the ulnar aspect of one hand vertically over the axilla, then place the ulnar aspect of the opposite hand along the midline of the upper arm laterally.

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

Place your thumbs together over the arm.

  • This identifies the vertical line of insertion on the proximal humerus

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

Palpate deeply as you climb up the humerus to the surgical neck.

  • It will feel like a golf ball on a tee – the spot where the “ball” meets the “tee” is the surgical neck

  • The insertion site is on the most prominent aspect of the greater tubercle, 1 to 2 cm above the surgical neck

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index


Clean the site

Point the needle set tip at a 45-degree angle to the anterior plane

Push the needle tip through the skin until the tip rests against the bone (5mm should still be visible)

  • Gently drill into the humerus 2cm or until the hub reaches the skin in an adult (you may feel a ‘POP’ or loss of resistance)

  • The hub of the needle set should be perpendicular to the skin

  • Hold the hub in place and pull the driver straight off

  • Continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations

  • The needle should feel firmly seated in the bone (1st confirmation of placement)

  • Attach a primed EZ-Connect® extension set to the hub, firmly secure by twisting clockwise

  • Aspirate for blood/bone marrow (2nd confirmation of placement)

  • Secure the arm in place across the abdomen

Proximal Tibia Identification and Insertion:


Extend the leg.

Insertion site is approximately 2cm medial to the tibial tuberosity, or approximately 3cm (two finger widths) below the knee and approximately 2cm medial, along the flat aspect of the tibia. (The flat spot below your knee toward the inside leg)

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index


Clean the site

Aim the needle set at a 90-degree angle to center of the bone

Push the needle set tip through the skin until the tip rests against the bone (5mm should still be visible)

  • Gently drill, advancing the needle set approximately 1-2cm after entry into the medullary space (you’ll feel a ‘POP’ or loss of resistance) or until the needle set hub is close to the skin

  • Hold the hub in place and pull the driver straight off

  • Continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations.

  • Attach a primed EZ-Connect® extension set to the hub, firmly secure by twisting clockwise

  • Aspirate for blood/bone marrow (2nd confirmation of placement)

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

For any site used, once the needle has been inserted, it should be secured with a commercial device or tegaderm. When removing the inner needle, dispose of it in a sharps immediately.

As I mentioned above, insertion of the IO is actually not very painful. It averaged 3/10 on the pain scale. That being said, the initial flush and subsequent drug boluses are “OMG HOLY SHIT WHAT IS HAPPENING MY STAB WOUNDS NO LONGER HURT JUST THIS” Painful. Thus, on a conscious patient, the extension set should be primed with 2% Lidocaine and 40mg (0.5mg/kg pediatric) infused slowly over 120 seconds. The medication should be allowed to dwell in the space for 60 seconds. Then flush with normal saline (5-10ml adult, 2-5ml pediatric). Then half of the initial dose of lidocaine should be administered over 60seconds.

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index

If the patient is unconscious, then a normal saline flush of 10-20ml will suffice prior to drug/fluid infusion.

It is important to remember that the bone marrow offers more resistance than would the intravenous space and as such it may be necessary to hang fluids/blood on a pressure bag or pump. Although resistance should be present, flushing should not be overly difficult.

Contraindications to IO insertion:

  • Prosthesis or previous orthopedic procedures near the insertion site - if you see a surgical scar over the insertion site, choose a different site.

  • Do not place if there is trauma or a suspected fracture in the insertion site.

  • Inability to locate the bony landmarks at the insertion site. No blind insertions people!

  • Obvious infection at the insertion site

  • IO insertion at the site in the last 48 hour

The IO has a life of 24hours and then should be removed since other access should have been obtained. To remove, screw a 10ml syringe onto the hub of the needle and while puling upward, rotate clockwise. Wear a face shield while removing the IO as they like to ‘pop’ out and splatter on your face….Yum. The needle will be exposed so immediately place in a sharps container.

Cross-section of IO device within the vascular bone marrow (Intramedullary space)

Source: https://www.teleflex.com/usa/en/clinical-resources/ez-io/index




Davlantes C, Miller LJ, Montez DF, Puga TA, Philbeck TE. Intraosseous catheter dwell-time appears safe for up to 48 hours: a preliminary report. The Journal of Vascular Access 2016;17(4):e26

Dolister M, Miller S, Borron S, et al. Intraosseous vascular access is safe, effective and costs less than central venous catheters for patients in the hospital setting. J Vasc Access 2013;14(3):216-24. doi:10.5301/jva.5000130.

Johnson M, Inaba K, Byerly S, et al. Intraosseous infusion as a bridge to definitive access. Am Surg 2016;82(10):876-80

Paxton JH, Ottolini J, Wilburn JM, Sherwin RL, Courage C. Does the choice of vascular access device delay appropriate emergency department resuscitation of adult out-of-hospital cardiac arrest patients? Ann Emerg Med 2015;66(4s):s35

Shina A, Baruch EN, Shlaifer A, et al. Comparison of two intraosseous devices: the NIO versus the EZ-IO by novice users- a randomized cross over trial. Prehosp Emerg Care 2017;21(3):315-21. doi: 10.1080/10903127.2016.1247201