Is IO (intraosseous) cannulation an underutilized method of emergency vascular access?

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A 40-year-old gentleman is brought into your Emergency Department by EMS in Pulseless Electrical Activity (PEA) arrest. With CPR in progress, monitors being placed, and epineprine being prepared, both nurses on either side of the patient report they couldn’t get IV access. A third nurse tries. Then a fourth. What should be done next?

What is IO access, and when should it be used?

Obtaining vascular access to deliver fluids, medications, and blood products is a top priority in the management of acutely or critically ill patients.​1,2​ Trauma and cardiac life support guidelines recommend intraosseous (IO) cannulation as the first alternative to failed or delayed peripheral IV access.​1–3​ IO is an effective and reliable method of rapid access via a non-collapsible intramedullary venous plexus in bony cortices and has a higher first-attempt success rate than IV access in hypotensive trauma patients.​3,4​ It can be established quickly (within 60 seconds with EZ-IO kits), in all age groups, and can administer any medication/fluid infusible intravenously.​2,5​ Despite its lifesaving benefits, studies show that IO access is infrequently used compared to central venous catheterization when indicated, especially in adult resuscitations.​1,6,7​ Barriers to IO utilization include a lack of team comfort with the procedure and concerns about volume/flow rate, delay in care, site selection, and complications.​1​

Contraindications?

There are no absolute contraindications for IO access in general. Some situations where you might consider an alternative access site include: previous attempts in the same bone, fracture, crush injuries, or circulatory compromise proximal to the site, infection in overlying/surrounding tissues, and medical conditions with fragile bones (eg. osteogenesis imperfecta).​4,5​

What are the IO site options and landmarks?

Common sites in ED settings for both adults and pediatric patients include proximal tibia (easier to landmark) and proximal humerus (higher flow rate), as well as distal tibia. *Distal femur is a pediatric-only option. See Figure 1 and Table 1 below.

Intraosseous cannulation anatomical sites
Figure 1. Anatomical sites for interosseous cannulation in pediatric vs. adult patients.
SiteLandmarkApprox. Flow Rate
Proximal humerusAdduct & internally rotate arm. Find greater tubercle. Aim needle at 45° angle (toward opposite hip)300cc/min
Distal femur (Pediatric Only!)Extend the leg. 1-2 cm proximal to the superior patellar border, 1 cm medial to midline. Aim 90° to bone.100cc/min
Proximal tibiaExternally rotate leg. 1-3 cm medial and distal to tibial tuberosity, along flat aspect of anterior tibia. Aim 90° to bone.200cc/min
Distal tibia3 cm proximal to medial malleolus. Find flat centre of tibia. Aim 90° to bone.100cc/min
Table 1. Anatomical sites and landmarks for interosseous cannulation, with approximate flow rates per site.

Placement Steps:

  1. Select an insertion site and needle size from your IO kit (weight-based or by estimating soft tissue depth). When in doubt, consider a longer needle.
  2. Landmark (see Table 1).
  3. Using a standard sterile technique, insert the needle perpendicular to the bone and push until the needle rests against the bone.
  4. Squeeze the stylet trigger and apply gentle pressure until you feel a loss of resistance as the needle enters the intramedullary space.
  5. Confirm placement by aspirating and flushing with saline.
  6. Remove the stylet/kit, apply a stabilizer or securement device, and document the time of insertion.

What’s the catch?

The main limitations of IO access include inaccuracy in the bloodwork drawn from an IO, common occurrence of needle dislodgement, and increased risk of complications for use >24 hours.​4,5​ After the initial resuscitation/stabilization, IV access (either peripheral or central) should be obtained for ongoing blood draws and administration of therapies.

Complications include site infection (cellulitis, osteomyelitis), fracture, fat embolism, and fluid extravasation with a risk of compartment syndrome.​4​ In pediatric patients, ensure IO sites are away from the epiphyseal plate to reduce the risk of plate necrosis.​4​

Conclusions

For acutely ill patients with failed or delayed IV access, IO is a safe, effective, and reliable method of vascular access which allows for prompt delivery of fluid resuscitation, medications, and point-of-care labs until an IV can be obtained.​2,3​ For your next resuscitation with difficult IV access, think of the mantra “1, 2, IO”.

This post was copy-edited by Noaah Reaume and was edited by Rey Nair.

  1. 1.
    James C, Rosenberg H, Vaillancourt C. Barriers and facilitators to intraosseous access in adult resuscitations when peripheral intravenous access is not achievable. Acad Emerg Med. 2014;21(3):250-256. doi:10.1111/acem.12329
  2. 2.
    Szydlowski B, Nolte J, Vershilovsky E. Recent Advances in Intraosseous Vascular Access. Curr Emerg Hosp Med Rep. Published online July 8, 2021:82-88. doi:10.1007/s40138-021-00231-y
  3. 3.
    Wang D, Deng L, Zhang R, Zhou Y, Zeng J, Jiang H. Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis. World J Emerg Surg. 2023;18(1):17. doi:10.1186/s13017-023-00487-7
  4. 4.
    Dornhofer P, Kellar J. Intraosseous Vascular Access. StatPearls Publishing; 2023.
  5. 5.
    Helman A, Swaminathan A, Klaiman M, Rosenberg H, MacDonald A, Morgenstern J. Massive PE, Gabapentin for Alcohol Withdrawal, Dental Avulsions, Pediatric Eye Exam, Best Resuscitation Fluid. EM Quick Hits. 2019. Accessed May 2024. EM Quick Hits 1 Massive PE, Gabapentin for Alcohol Withdrawal, Dental Avulsions, Pediatric Eye Exam, Best Resuscitation Fluid
  6. 6.
    Bloch S, Bloch A, Silva P. Adult intraosseous use in academic EDs and simulated comparison of emergent vascular access techniques. Am J Emerg Med. 2013;31(3):622-624. doi:10.1016/j.ajem.2012.11.021
  7. 7.
    Voigt J, Waltzman M, Lottenberg L. Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis. Pediatr Emerg Care. 2012;28(2):185-199. doi:10.1097/PEC.0b013e3182449edc

Reviewing with Staff

In Emergency Medicine, acutely ill patients requiring immediate venous access is very common. Delays in venous access can increase morbidity and mortality of patients. Peripheral IVs are often started in the pre-hospital setting, and sometimes in the Emergency Department by nurses. In the past, delays in securing a peripheral IV would have necessitated a central venous access procedure. These tend to be more time-consuming and can often be technically difficult, especially in certain patient populations (e.g. active seizures, agitation, body habitus, ongoing code, etc.). The emergence of IO cannulation for venous access in acutely ill/critical patients has become the current standard of practice and is the recommended procedure now. It allows rapid venous access and technically is usually considered an easier skill to learn. Getting comfortable with this procedure is critical in the practice of Emergency Medicine.

Dr. Indraneel (Indy) Ghosh
Dr. Indraneel (Indy) Ghosh is an Emergency Physician and Chronic Pain Physician, specializing in medical cannabis. He graduated medical school from Queen’s University, and then completed his residency at U of T, followed by a fellowship at McMaster University. His first foray into senior leadership was in academia, as the Program Director for the CCFP Emergency Medicine Fellowship training program. From there, he was recruited to Director of Medical Education and Research at Mackenzie Health Hospital. Subsequently, he was appointed as Chief & Medical Director of the Emergency Department at Mackenzie Health. After completing his term, he was then appointed as Chief & Medical Director of the Emergency Department at Chatham Kent Health Alliance, and subsequently promoted to Senior Medical Director of Strategy, Access and Flow. Currently, he practices at THP and is also a Board Member at several non-profit organizations, including the Canadian Association of Pain Management (CAPM), Hamilton Brain Injury Association (HBIA), and TheHealthLine.ca. There are no conflicts of interest with this article.
Ming Li

Ming Li

Dr. Ming Li is a Family Medicine resident at the University of Toronto with a keen interest in emergency medicine. She is involved in medical education through scholarly projects, clinical teaching/supervision, and mentorship. Outside of medicine, she enjoys camping, hiking, traveling, and binge-watching TV shows.