Intraosseous Access

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Intraosseous (IO) access, in order to provide medication and fluid products to the central circulation, was first suggested in 1922 By Drinker. Between 1922 and the 1980’s there’s been sparse evidence mentioning IO due to the arrival of intravenous (IV) access devices able to deliver the same treatments. Since then, literature surrounding rapid infusion of fluids have refocussed on the use of IO access where IV  has been difficult, due to user failure and/or patients with poor circulatory volume. With the incidence of military conflict and the formation of specialist pre hospital care teams with enhanced skills, further evidence surrounding IO access has been published recognising the benefits in the severely shocked patients. Additionally, usefulness in scenarios where IV access is either technically or environmentally difficult is acknowledged. In 2005 in the United States of America and from 2011 in the United Kingdom IO use has been routinely recommended in the cardiac arrest patient, both adult and paediatric, where IV access may be delayed.


A device, which is inserted directly into the medullary space of bone, allowing the delivery of fluid and medications directly into the vascular system.


There is slight variation exactly when an IO device should be inserted. A consensus does exist though that in critically unwell patients with anticipated difficult IV access an immediate IO access is appropriate, or where 2 attempts have been undertaken and not been successful. In addition a consensus that in the arrested patient IO may be the first line access preference. This is more prevalent in the major trauma patient where early and aggressive fluid resuscitation with blood, as recommended in the new Major Trauma Cardiac Arrest algorithm .

Which site?

Don’t forget that different products are only recommended for certain sites… e.g. sternal access you can only use the FAST device…at the moment… Here is a little breakdown of which manufacturer recommends which site…

Site Device Advocated Landmark
Proximal Tibia EZIO, BIG, NIO, Cook ALS, PHTLS, ATLS, APLS, EPLS 2-3 cm below the tibial tuberosity on the antereomedial aspect (BIG 1cm/1cm paeds)
Distal Tibia EZIO PHTLS, EPLS 3 cm above the medial malleolus
Distal Femur EZIO, Cook, APLS, EPLS,Truemper et al. (2012) (Literature review) 3 cm above the lateral epicondyle
Humeral head EZIO, NIO ALS, Adduct and rotate the shoulder medially. Locate acromion and coracoid process. Midway-palpate distally towards elbow until reaching greater tuberosity.
Sternum FAST (Adults only) PHTLS At sternal notch, in the manubrium at the upper cephelad portion of the sternum.
Calcaneum Not disclosed Single case study. McCarthy, G et al. (1998) The Calcanium as a site for Intraosseus Infusion. Journal of Accident and Emergency Medicine. 15(6). 421. Medial aspect with external/rotation at the hip.
Iliac crest Mentioned in NIO Paper. Not advocated/licensed .Military experience NIO specific paper Above tubercle of Iliac Crest
Distal Radius Not disclosed Mentioned in one paper. Not specified

Manufacturer-sponsored video on Proximal Tibia and Humeral Head

Manufacturer-sponsored video on Sternal access

Volume and speed of infusion

From the literature reviewed the majority of the studies compared humeral head IO infusions rates with Tibia Plateau. Of the seven studies reviewed, six identified that humeral head site was preferable where infusion rates ranged from 41 mls/min to 213 mls/min for humeral head and 15 mls/min to 165 mls/min. The only studies that reviewed and compared the sternal site with other sites preferred the sternal site with 93.7 mls/min compaired with 57.1 mls/min in the humeral head as closets comparison. The studies unanimously agreed that in all cases delivery with 300mg/hg of pressure was essential to get effective effusion rates.

Speed to central circulation

We found 3 studies found looking at time to central circulation compared with IV routes looking at drug effect and serum concentration levels. They found IO administration equivalent to IV access. Of the sites the sternal site appears to be the fastest to central circulation, with humeral head being a close second.

Ease of use

The literature is pre hospital heavy when it comes to selecting a site and in this environment the studies have found that the tibial plateu is preferable. This was mainly due to an increase in dislodgments in the humeral head site and more difficulty in locating the landmarks. There is contradiction across the literature on time taken to insertion but what is conclusive is that IO access, from a time perspective is more efficient than IV access and definitely CVC access.


Of the three studies found there are issues surrounding sponsorship, methodology and interpretation of results when looking at using local anesthetic to flush the device with. The most painful point is the initial flush, which open up the medullary space with the volume of flush.

What was found is that the Humeral head is subjectively less painful than other sites.

It is more painful to insert an IO than to have an IV. Consider this when inserting into conscious patients. There is no clear, well constructed work done yet to determine the best way to mitigate and manage this

Bottom line

The humeral IO has good success rates on access, admittedly more dislodgments that tibia (in pre hospital studies) and good infusion rates from a volume and time to central circulation perspective. Additionally in the conscious patient, the small volume of literature does appear to suggest that the humeral head is less painful that other sites.

It has been suggested that the humeral head should be utilised where you can secure the IO device and minimize movement to reduce dislodgement. If this is not possible then the proximal tibia is probably your next best option.

On paper, the best site is the sternum IO to deliver fluids and drugs to the patient. However this can effect compressions during cardiac arrest, can be ineffective in the trauma patient with chest injuries and with only one product available currently, not commonly used results in other sites being preferred. So probably not one for the mainstream yet.

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Inserting an IO

1.         Know your device. Get it out. Look at it. Look at what the manufacturers recommend

2.         Secure the limb that you are inserting the device into.

3.         Keep it clean. Take a few seconds to make sure the site is cleaned prior to insertion.

4.         Draw back once inserted. Reasure yourself it is in place. Not all IO’s draw marrow back… Attempt to flush some volume then try to draw back again… You may have a plug on he device

5.         Use systemic analgesia / dissociative medication / amnesic / along with the flush if your patient is likely to have experienced discomfort on insertion. The evidence on local anesthetic use isn’t powerful enough.

6.         Secure, secure, secure. You’ve worked hard to get it in…don’t loose it now. (See pictures)

7.         Once in…if possible keep looking for IV access as you increase circulating volume 



References/Reading list

Advanced Life Support Group (ALSG) (2011) Advanced Paediatric Life Support Manual. 5th ed. John Wiley and Sons: Manchester.

American College of Surgeons (2012) Advanced Trauma Life Support. 9th ed.

Barnard, E. et al. (2014) Rapid Sequence Induction of Anaesthesia via IO access: A prospective observational study. Academic Emergency Medicine Conference. 21(5 SUPPL 1): S79

Burgert, J. et al. (2014) An evidence based review of epinephrine administered via the IO route in anal models of cardiac arrest [review]. Military Medicine. 179(1): 99-104.

Byars, D. et al. (2011) Evaluation of Success rate and access time for an adult sternal IO device deployed in Prehospital care setting. Prehospital and disaster medicine. 26(2):127-29.

Calkins, M. et al. (2000) IO infusion devices: a comparison for potential use in special operations. Journal of trauma Injury, Infection and Critical Care. 48(6): 1068-74.

European Resuscitation Council (2015) European Trauma Course Manual. v1.9. European Resuscitation Council: London.

Flamm, A et al. (2015) Utilizing the NIO to gain Intraosseous Vascular access.

Academic Emergency Medicine Conference: 2015. 22 (5 Suppl 1): S150.

Frascone, R. et al. (2007) Consecutive field trials using two different intraosseous devices. Prehospital Emergency Care. 11: 164-71.

Hafner, J. et al. (2013) Effectiveness of a drill assisted IO catheter vs manual IO catheter by resident physicians in a swine model. Western Journal of Emergency Medicine. 14(6): 629-32.

Hartholt, K. et al. (2010) Intraosseous Devices: A randomized control trial comparing three devices. Prehospital Emergency Care. 14: 6-13.

Helm, M. et al. (2015) EZ-IO intraosseous device implementation in German Helicopter Emergency Medical Services. Resuscitation. 88: 43-47.

Joint Royal College Ambulance Liaison Committee (JRCALC) (2013) UK Ambulance Services Clinical Practice Guidelines. JRCALC: Warwick.

Kehrl, T. et al. (2011). Relationship of body mass index and increased difficulty with IO needle placement: Assessment of tissue depth using US.

Annals of Emergency Medicine. 15(2): 278-281.

Lairet, J. et al. (2013)A Comparison of proximal tibia, distal femur, proximal humerous infusion rates using the EZIO IO device on the adult swine model.

Prehospital Emergency Care. 17(2): 280-4

Lairet, J. et al. (2013) Comparison of Intraosseous infusion rates of plasma under high pressure in an adult hypovolemic swine model in two different limb sites. Academic Emergency Medicine Conference. 20 (5 SUPPL 1): S13.

Lamhaut, L. et al. (2010) Comparison of IV and IO access by pre hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation. 81(1): 65-8.

Lee, P. et al. (2015) IO vs CVC utilization and performance during inpatient emergencies. Critical Care Medicine. 43(6): 1233-1238.

Leidel, B. et al. (2010) Comparison of two IO access devices in adult patients under resuscitation in the ED: A prospective randomized study. Resuscitation 81(8): 994-999.

Macnab, A. et al. (2000) A new system for sternal IO infusion in adults. Prehospital Emergency Care. 4: 173-77.

Miller, L. et al. (2010) A two-phase study of fluid administration measurement during intraosseous infusion. Annals of Emergency Medicine. 53(3): S151.

National Association of Emergency Medical Technicians (US) (NAEMT) (2014) Pre Hospital Trauma Life Support. Instructor Course Manual. 8th ed. Jones and Bartlett Learning: Burlington.

Ong, M. E. (2009) An observational, prospective study comparing tibial and humeral intraosseous access using the EZIO. American Journal of Emergency Medicine. 27(1): 8-15.

Pasley, J. et al. (2015) Intraosseous infusion rates under high pressure. A cadaveric comparison of anatomical sites. The Journal of Trauma and Acute Care Surgery. 78(2): 295-9.

Paxton J. et al. (2009) Proximal Humerus IO infusion: A preferred Emergency Venous Access. Journal of Trauma, Infection and Critical Care. 67(3): 606-

Philbeck, T. et al. (2009) Hurts so good. Easing IO pain and pressure. Journal of Emergency Medical Services. 35: 58-62.

Philbeck, T. et al. (2009). Pain Management during Intraosseous infusion through the proximal humerous. Annals of Emergency Medicine. 54(3 Suppl 1): S128

Reades, R. et al. (2010) Comparison of first attempt success between tibial and humeral IO insertions during out of hospital cardiac arrest. Academic Emergency Medicine Conference. 17: S65

Reades, R et al. (2011) Comparison of first-attempt success between tibial and humeral intraosseous insertions during out of hospital cardiac arrest. Pre Hospital Emergency Care. 15(2): 278-281

Reades, R. (2011) IO vs IV access during Out-of-Hospital Cardiac Arrest. An RCT. Annals of Emergency Medicine. 58(6): 509-516.

Shavit, I. et al. (2009) Comparison of two mechanical IO infusion devices: a pilot, randomised crossover trial. Resuscitation. 80(9): 1029-33.

Tan, B. et al. (2012) EZIO in the ED: An observational, prospective study comparing flow rates with proximal and distal tibia IO access in adults. American Journal of Emergency Medicine. 30(8): 1602-06.

United Kingdom Resuscitation Council (2015) Advanced Life Support Course Materials. United Kingdom Resuscitation Council: London.

United Kingdom Resuscitation Council (2010) European Paediatric Life Support Course Materials. 3rd Ed. United Kingdom Resuscitation Council: London.

Von Hoff, D. et al. (2008) Does IO equal IV? A pharmacokinetic study. American Journal of Emergency Medicine. 26(1): 31-38.

Warren, D. et al. (1993) Comparison of fluid infusion rates among peripheral intravenous and humerous, femur, malleolus and tibial IO sites in norvovolemic and hypovolemic piglets. Annals of Emergency Medicine. 22(2): 183-6.

Waisman, M. et al. (1997) Bone Marrow infusion in adults. Journal of Trauma-injury Infection and Critical Care. 42: 288-93.


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