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.


1️⃣ 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!


2️⃣ 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!


3️⃣ 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!


4️⃣ 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!


5️⃣ 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!


6️⃣ 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!


7️⃣ 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!


8️⃣ 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.


9️⃣ 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!