INTRAOSSEOUS (IO) ACCESS: RAPID EMERGENCY VASCULAR ACCESS
Intraosseous (IO) access provides rapid vascular access by inserting a needle into the bone marrow, allowing for the administration of fluids, medications, and blood products. It is life-saving in emergencies when IV access cannot be quickly established.
Why It’s Important:
Faster than IV access when veins are difficult to find. Delivers medications, fluids, and blood just as effectively as IV routes. Essential for cardiac arrest, shock, and critical trauma patients.
INDICATIONS FOR IO ACCESS
Use IO Access When:
Peripheral IV access cannot be obtained within 90 seconds or after two failed attempts. Cardiac arrest (all types). Shock (hypovolemic, distributive, or cardiogenic). Severe dehydration (e.g., pediatric patients, burns). Critical trauma where IV access is difficult.
Key Takeaway: IO access is a first-line alternative to IV in emergencies—don’t delay!
CONTRAINDICATIONS FOR IO ACCESS
Do NOT use IO if:
Fracture at or above the insertion site (risk of extravasation). Previous IO attempt at the same site within 24 hours (increased complication risk). Infection or cellulitis at the insertion site (risk of osteomyelitis). Severe osteoporosis or osteogenesis imperfecta (risk of fracture). Inability to identify anatomical landmarks (high insertion failure rate).
Key Takeaway: If one IO site is contraindicated, consider an alternative site!
COMMON IO INSERTION SITES
Proximal Tibia (Preferred Site in Adults & Children)
- Location: 2-3 cm below the tibial tuberosity (bony prominence below the kneecap).
- Why? Easily accessible, large marrow cavity, minimal overlying tissue.
Proximal Humerus (Alternative Site, Faster Systemic Absorption)
- Location: Greater tubercle of the humerus, just below the shoulder joint.
- Why? More direct entry into central circulation, but requires correct positioning.
Distal Tibia (Backup Site)
- Location: 3 cm above the medial malleolus (inside ankle bone).
- Why? Less preferred but still effective.
Key Takeaway: Choose the site based on patient condition, provider experience, and accessibility!
EQUIPMENT FOR IO INSERTION
IO Needle/Device – Various types available: Manual IO Needles – Require twisting motion to insert. Battery-Powered IO Drills (e.g., EZ-IO) – Faster, preferred in most hospitals.
Antiseptic Solution – Chlorhexidine, povidone-iodine, or alcohol to clean insertion site. Local Anesthetic (If Time Permits) – Lidocaine (2% without epinephrine) for conscious patients. Syringe with Normal Saline – Flush after insertion to ensure patency. Stabilization Device or Secure Dressing – Prevent accidental dislodgement.
Key Takeaway: Power drills (EZ-IO) provide faster and more reliable insertion!
IO INSERTION PROCEDURE (PROXIMAL TIBIA)
Step 1: Locate the Insertion Site
Identify the flat medial surface of the proximal tibia, 2-3 cm below the tibial tuberosity.
Step 2: Clean the Skin
Use antiseptic solution to disinfect the insertion area.
Step 3: Insert the IO Needle
Insert perpendicular to the bone (90° angle). Use a twisting or drilling motion to advance until you feel a “pop” (sudden loss of resistance) – this indicates entry into the marrow.
Step 4: Remove the Stylet
Take out the inner needle (stylet) while keeping the outer catheter in place.
Step 5: Aspirate & Confirm Placement
Aspirate bone marrow (not always possible). Flush with 5-10 mL of saline to confirm patency.
Step 6: Secure the IO Device
Use a stabilization device or secure with dressing to prevent movement.
Key Takeaway: Correct technique is crucial to avoid extravasation and complications!
IO INFUSION & MEDICATION ADMINISTRATION
ALL ACLS Medications & Fluids Can Be Given Via IO! Dosing for IV and IO routes is the same. Give a FORCEFUL Normal Saline Flush (5-10 mL) before medication administration. Infuse medications with pressure (gravity alone is ineffective).
Common IO-Administered Medications
Epinephrine (1 mg IV/IO) – For cardiac arrest. Amiodarone (300 mg IV/IO) – For VF/pVT. Lidocaine (1-1.5 mg/kg IV/IO) – Alternative to Amiodarone. Atropine (0.5 mg IV/IO) – For bradycardia. Fluids (NS/LR, Blood Products) – For shock/hypovolemia.
Key Takeaway: A forceful saline flush ensures effective drug delivery via IO!
COMPLICATIONS OF IO ACCESS
Extravasation (Leakage into Soft Tissue) Occurs if the needle is misplaced or dislodged. Check for swelling or poor infusion flow.
Compartment Syndrome Severe swelling due to fluid buildup in muscle compartments. Leads to tissue necrosis if untreated.
Osteomyelitis (Bone Infection) Rare but can occur if IO access is left for too long (>24 hrs). Strict aseptic technique reduces risk.
Fracture (Bone Damage) Higher risk in osteoporotic or pediatric patients.
Key Takeaway: Monitor the insertion site frequently to prevent complications!
IO ACCESS KEY CONSIDERATIONS
IO is a temporary measure – transition to IV access as soon as possible. Fluids and medications must be pushed with pressure for rapid absorption. Use local anesthetic (Lidocaine 2%) for conscious patients before infusion to reduce pain. Remove the IO device within 24 hours to prevent infection or bone complications.
Key Takeaway: IO access is a bridge to IV access and should not be left in place longer than necessary.
SUMMARY: MASTERING IO ACCESS
When to Use IO Access:
Emergencies when IV access is not available (cardiac arrest, shock, trauma). Preferred sites: Proximal tibia, humerus, distal tibia.
IO Insertion Steps:
Locate site → Clean with antiseptic → Insert at 90° angle → Feel for “pop” → Remove stylet → Flush & confirm placement. ALL IV medications can be given via IO at the same doses. Flush with force (5-10 mL saline) before administration.
Complications to Watch For:
Extravasation → Check for swelling & pain. Compartment syndrome → Stop infusion if signs of severe swelling. Osteomyelitis → Remove IO access within 24 hours.
Takeaway: IO access is a life-saving alternative when IV access fails—quick insertion and correct technique are key!