Intraosseous IO Insertion Guide
Posted on: April 8, 2025, by : Haroon Shaukat MD
✅ When to Use an IO
Indications (Emergent situations when IV access is delayed or impossible):
- Cardiac arrest
- Shock or severe hypovolemia
- Status epilepticus needing immediate IV medications
- Severe dehydration
- Trauma with difficult vascular access
- Any critical condition requiring rapid vascular access within 60–90 seconds
Consider IO when:
- <2 IV attempts or >90 seconds without access
✅ Equipment Needed:
- IO device (battery-powered drill, manual driver, or spring-loaded device)
- Examples: EZ-IO®, BIG®, manual Jamshidi needle
- Appropriately sized IO needle (based on patient size/weight):
- Pink (15 mm) – Infants/small children
- Blue (25 mm) – Children/adults
- Yellow (45 mm) – Large adolescents/obese patients
- Antiseptic wipes (chlorhexidine or alcohol)
- Extension tubing/primed IV line
- 10 mL saline flush
- Pressure bag or syringe for infusion
- Local anesthetic (Lidocaine) if patient is conscious
✅ Common IO Insertion Sites:
| Site | Landmark & Notes |
| Proximal Tibia (Most Common) | 2 cm below the tibial tuberosity, medial flat surface |
| Distal Femur (Infants) | 2–3 cm above the patella, midline |
| Distal Tibia | Proximal to the medial malleolus |
| Proximal Humerus | Older children/adolescents—lateral aspect near the greater tubercle (consider in CPR) |
💡 Tip: Avoid sites with fractures, infection, or prior attempts.
✅ Insertion Steps:
- Position patient securely and expose the chosen site.
- Prep the skin with antiseptic in a circular motion—allow to dry.
- Stabilize the limb and identify the correct landmark.
- Insert the IO needle:
- Power driver or manual twist
- Stop advancing when a “pop” or loss of resistance is felt (entry into the marrow space)
- Remove the stylet and secure the needle hub.
- Confirm placement:
- Aspirate marrow (may or may not succeed)
- Flush with 10 mL saline—should flush easily without resistance or extravasation
- Secure the IO site with stabilizer or tape.
- Begin infusions—may require a pressure bag or syringe push.
✅ Contraindications:
- Fracture of the target bone
- Overlying infection or burn at the site
- Previous IO attempt in the same bone
- Bone disease (osteogenesis imperfecta)
🔗 Optional Video Demo for Simulation: