- 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 (e.g., proximal humerus on small pediatrics).
- Accessing the humeral head for IO insertion is restricted to those over the age of 12 and greater than 55 kg.
- 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.
- The proximal tibia should be utilized as the primary insertion site for all patients under the age 12 and less than 55 kg.
- 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.
- 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 2 cm or until the hub reaches the skin in an adult.
- 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, 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 IV 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).