Page 213 - 2026 SMOG

VASCULAR ACCESS (INTRAOSSEOUS)
Clinical Indications
• Need for intravascular access to provide resuscitative fluids and/or medications with inability to
obtain adequate peripheral intravascular access (2 failed attempts or greater than 90 seconds)
• Anticipated need for intravenous access in emergency patients
Contraindications
• The only absolute contraindication is a fracture at the affected site or a prior IO attempt in the
same bone.
• Cellulitis overlying puncture site (relative contraindication)
• Injury (not fracture) proximal to puncture site (relative—site-dependent)
• FAST Tactical device is contraindicated in pediatric patients less than 18 years old
™
Procedure
• Prepare all necessary equipment: PPE, IO device, Betadine scrub, and IV tubing
• Ensure all IV tubing/saline locks are flushed prior to attempting IV
• Identify the appropriate puncture area as follows:
˚ FAST Tactical ™
■ Sternum—follow manufacturer instructions or training guidelines.
˚ EZ IO ™
■ Proximal Humerus (YELLOW 45mm)—1–2cm above the surgical neck into the most
prominent aspect of the greater tubercle lateral to the intertubercular (bicipital) groove,
aiming 45-degrees downward towards the contralateral hip
■ Distal Femur (peds, BLUE 25mm)—Proximal to patella (max 1cm) and 1–2cm medial
to midline
■ Proximal tibia (BLUE 25mm or PINK 15mm)—2cm (2 finger widths) distal to tibial
tuberosity on medial aspect
■ Distal tibia (BLUE or PINK)—2cm (2 finger widths) proximal to medial malleolus
˚ Manual IO
™
■ Proximal tibia and distal tibia—are the same as the EZ IO site
• Cleanse the site well, as failure to appropriately disinfect the area can lead to bone infections
• Applying firm pressure, puncture skin at a 90° angle (45° down for Humeral IO), puncture bone
(felt as loss of resistance, give or “pop”)
˚ Confirm placement by (1) needle feeling firm in bone and (2) aspiration of blood/bone
marrow. If unable to aspirate blood, attempt to aspirate after the flush
˚ Flush the IO catheter with normal saline. May add 2% preservative-free Lidocaine without
Epinephrine to flush to decrease pain (2mL or 40mg in adults, 0.5mg/kg not to exceed 40mg
in pediatrics)
˚ Constantly monitor for increased tension in muscular compartments, as misplacement into
a compartment with subsequent fluid administration can lead to iatrogenic compartment
syndrome
˚ With the exception of adult proximal humerus insertions, routinely inserting the needle set to
the hub is not a recommended technique
**Document procedure, results, and vital signs.**

2026 Standard Medical Operating Guidelines (SMOG) • 205