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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 90sec).
• Anticipated need for intravenous access in emergency patients.
CONTRAINDICATIONS:
• Only absolute contraindication is fracture at affected site or 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 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 flushed prior to attempting IV.
• Identify appropriate puncture area as follows:
o FAST Tactical™
 Sternum – follow manufacturer instructions or training guidelines.
o EZ IO™
 Proximal Humerus (YELLOW 45mm) – 1 to 2 cm above the surgical neck into the most prominent
aspect of the greater tubercle lateral to intertubercular (bicipital) groove, aiming 45-degrees
downward towards 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.
o Manual IO
 Proximal tibia and distal tibia – same as EZ IO™ site.
• Cleanse site well as failure to appropriately disinfect the area can lead to bone infections.
• Applying firm pressure, puncture skin at 90° angle (45 degree down for Humeral IO), puncture bone (felt as loss of
resistance, give or “pop”).
- Confirm placement by (1) needle felling firm in bone and (2) aspiration of blood/bone marrow. If unable to aspirate blood,
attempt to aspirate after the flush
- Flush IO catheter with normal saline. May add 2% preservative-free Lidocaine without epinephrine to flush to decrease pain
(2mL or 40 mg in adults, 0.5mg/kg not to exceed 40mg in pediatric).
- 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 recommended
technique.
Document procedure, results, and vital signs.

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