Venous Access: Intraosseus (Pediatric, < 12)


 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.



  1. Proximal tibia (<12 years of age)
    1. Identify the tibial tuberosity located 2 finger-breaths below the base of the patella.
    2. The insertion site is 1-2 cm medial 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.
  2. Distal femur (<12 years of age)
    1. Secure site with leg outstretched to ensure knee does not bend.
    2. The insertion site is approximately 1-2 cm proximal to the superior border of the patella and approximately 1 cm medial to the mid-line (depending on patient anatomy).
    3. Aim the needle set tip at a 90-degree angle to the bone for insertion.




  1. Cleanse site using antiseptic agent and allow to air dry thoroughly.
  2. Prime the EZ-Connect extension set with approximately 1ml NS.
  3. Connect appropriate needle set to driver and stabilize site.
  4. Remove needle cap and position the driver at the insertion site with the needle set at a 90⁰ angle to the bone surface.
  5. Gently pierce the skin with the needle tip until the tip touches the bone.
  6. The 5 mm mark must be visible above the skin for confirmation of adequate needle length.
  7. Gently drill into the bone and stop at loss of resistance.
    1. Stop when you feel the “pop” or “give” in infants.
  8. 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.
    1. The needle should feel firmly seated in the bone (1st confirmation of placement).
  9. 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.
  10. Flush the catheter with 2-3 mL Normal Saline adults; look for infiltration (2nd confirmation of placement).
  11. If the patient is responsive to pain, administer 0.5 mg/kg (max single dose 20 mg) 2% Lidocaine, slow IO over 90 seconds for anesthetic effect prior to the saline flush. May give an additional 0.5 mg/kg for a max total dose of 40 mg.
  12. If the patient is responsive to pain, administer 0.5 mg/kg (max single dose 20 mg) 2% Lidocaine, slow IO over 90
  13. Begin infusion utilizing a pressure delivery system and continue to monitor extremity for complications.
  14. Any prehospital fluids or medications approved for intravenous (IV) use may be given IO.
  15. 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.
  • Adequate flow rates are dependent on performing a rapid normal saline flush (syringe bolus) prior to IO infusion and infusing fluids and medications under pressure (e.g. infusion pressure pump or pressure bag). Gravity alone will rarely generate adequate flow rates. An IV pressure bag capable of generating 300 mmHg pressure


 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.