Venous Access: Intraosseus (Adult)


Clinical Indications:


  • Where rapid, regular intravenous (IV) access is unavailable with any of the following:
    • Cardiac arrest (may be used as a first line vascular access).
    • Multisystem trauma with severe hypovolemia.
    • Severe dehydration with vascular collapse and/or loss of consciousness.
    • Respiratory failure/respiratory arrest.
    • Require life-saving medications that cannot be administered intramuscular (IM) or subcutaneous (SQ).




  • Fracture in bone or joint replacement of intraosseous (IO) site.
  • Current or prior infection at proposed IO site.
  • Previous IO insertion at proposed site within 48 hours.
  • Inability to find landmarks.
  • Prosthesis or previous orthopedic procedures near insertion site.




 Proximal Humerus


  • Proximal humerus (preferred site, > 12 years of age)
  • Place the patient’s palm on the umbilicus and elbow on the ground or stretcher or place the patient’s arm flat on the ground or stretcher with the palm facing downward.
  • Use your thumb to identify humeral shaft, slide thumb towards humeral head with firm pressure. Locate tubercule by prominent bulge.
  • Use the opposite hand to pinch interior and anterior humerus ensuring that you are midline on the humerus. If necessary, for further confirmation, locate the inter-tubercular groove.
  • With your finger on the insertion site, keeping the arm adducted, externally rotate the humerus 90⁰. You may be able to feel the inter-tubercular groove.
  • Rotate the arm back to the original position for insertion. The insertion site is 1-2 cm lateral to the inter-tubercular groove.


 Proximal tibia


  • Identify the tibial tuberosity located 2 finger-breaths below the base of the patella.
  • The insertion site is 1-2 cm medical from this bony prominence on the superior portion of the flat aspect of the proximal
  • tibia. Rotating the leg laterally can aid in positioning the site anterior.


  • Cleanse site using antiseptic agent and allow to air dry thoroughly.
  • Prime the EZ-Connect extension set with approximately 1ml NS.
  • Connect appropriate needle set to driver and stabilize site.
  • Remove needle cap and position the driver at the insertion site with the needle set at a 90⁰ angle to the bone surface.
  • Gently pierce the skin with the needle tip until the tip touches the bone.
  • The 5 mm mark must be visible above the skin for confirmation of adequate needle length.
  • Gently drill into the bone and stop at loss of resistance.
    • Stop when you feel the “pop” or “give” in infants.
  • Hold the hub in place and pull the driver straight off. Continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations.
    • The needle should feel firmly seated in the bone (1st confirmation of placement).
  • Place the stylet in a sharps container and secure site with EZ stabilizer and connect primed EZ-connect extension set to the hub, firmly secure by twisting clockwise.
  • Flush the catheter with 5-10 mL Normal Saline adults (2-3 mL pediatric); look for infiltration (2nd confirmation of placement).
    • If the patient is responsive to pain, administer 40 mg (2 mL) 2% Lidocaine, slow IO over 90 seconds for anesthetic effect prior to the saline flush. May give an additional 20 mg for a max dose of 60 mg.
  • Begin infusion utilizing a pressure delivery system and continue to monitor extremity for complications.
  • Any prehospital fluids or medications approved for intravenous (IV) use may be given IO.
  • Document the procedure, time, and result (success) on/with the patient care report (PCR).


 Additional Considerations:


  • It is essential to perform a rapid normal saline (NS) syringe flush into the IO space before attempting to infuse fluids through the IO access. A rapid syringe flush of 5-10 mL normal saline in adults and 2-5 mL normal saline in infants and small children helps displace the marrow and fibrin in the medullary space, facilitating effective infusion rates.


 Certification Requirements:


  • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by medical control.