Intraosseous cannulation is available as an option for paramedics requiring vascular access when peripheral attempts have failed.
Two unsuccessful peripheral IV attempts or an inability to visualize peripheral veins (including external jugular vein)
Unstable patient requiring medications or fluid replacement
Skeletal or tissue damage in the extremity to be used
Prior proximal tibial surgery or knee joint replacement
Signs of infection around the site
Assemble equipment, including EZ-IO driver, needle, primed EZ-Connect extension, infusion fluid and line set, and 20 mL syringe of normal saline.
Select the site of needle insertion and clean the skin.
Using aseptic techniques, drive the needle into the bone. Press gently: let the drill do most of the work.
Remove the stylet and securely discard the sharp. Place the stabilizer dressing over the needle hub.
Connect a primed EZ-Connect extension. (In patients who are conscious, prime the EZ-Connect extension with lidocaine - see step 7).
Aspirate for the presence of bone marrow or blood to confirm the placement. If patent, connect the IV tubing to the EZ-Connect extension set. If unsuccessful, change to another site on a different limb. Do not reuse the same limb.
In patients who are conscious, administer lidocaine, 40 mg (0.5 mg/kg in children to a maximum of 40 mg)
Instill the lidocaine slowly, over 120 seconds, making sure to flush the appropriate amount of lidocaine through the extension, and allow it to dwell in the bone marrow cavity for 60 seconds.
Slowly flush the IO catheter with 5-10 mL normal saline (2-5 mL in children) following the administration of lidocaine.
Connect the 20 mL syringe to the proximal access port on the IV tubing. Flush the line and the extension set, pushing firmly and briskly on the syringe plunger.
Set the appropriate flow rate. Pressure infusers or intermittent boluses may be required.
Protect the site and monitor for signs of extravasation.
Needle placement in the proximal humerus has been demonstrated to have significantly improved infusion rates compared to the tibial plateau. It should be considered as the preferred IO site in patients. If using the humerus, choose the larger (yellow) needle. To review anatomy and landmarks, see video below.
Paramedics should review this educational material for additional information about intraosseous site selection. Contact a Paramedic Practice Educator for specific questions or concerns.
Intraosseous catheters are approved for use in patients for up to 24 hours when placed in the proximal humerus and both the proximal and distal tibia. It may be extended for up to 48 hours in patients over the age of 12 under exceptional circumstances.