Every rookie dreads the moment: the patient is crashing, IV attempts are failing, and the clock is ticking. This is where intraosseous (IO) access saves lives. Fast, reliable, and safe — yet underused because rookies hesitate. Don’t be afraid to drill.
Why IO Access Matters
- In emergencies, IV access can be difficult or impossible (pediatric arrest, shock, trauma).
- IO access provides immediate entry to the central circulation.
- Flow rates are comparable to central venous lines.
- Can be placed in <30 seconds by trained providers.
Indications
- Cardiac arrest.
- Shock (septic, hypovolemic, anaphylactic) when IV not rapidly obtainable.
- Major trauma with collapsed veins.
- Pediatric resuscitation (tiny veins, time-critical).
- Any scenario where IV cannot be established within 90 seconds or 2 attempts.
Rookie pearl: IO is not “last resort.” It’s the first backup when IV fails.
Common Sites
- Proximal tibia (anteromedial surface): most common, especially in children.
- Distal tibia.
- Proximal humerus: faster flow rates in adults.
- Sternum (manubrium): requires special devices.
Devices
- EZ-IO drill system (most common).
- Manual IO needles (Jamshidi-type).
- Spring-loaded devices (FAST1 for sternum).
Technique (Simplified for Rookies)
- Identify site (palpate flat bone surface, avoid growth plates in kids).
- Prep skin with antiseptic.
- Insert IO needle at 90° angle (slight medial tilt for tibia).
- Advance until sudden “pop” → entry into marrow space.
- Aspirate bone marrow/blood to confirm placement.
- Flush with 10 mL saline (vigorous — prevents clogging and pain).
- Connect IV tubing and secure device firmly.
Medications and Fluids
- Anything IV can go IO: fluids, blood, vasopressors, resuscitation meds.
- Flow rates improved with pressure bag.
Pain Control
- IO access is painful in awake patients.
- Lidocaine 1% (0.5 mg/kg, max 40 mg) can be given into IO before infusion.
Complications
- Extravasation/compartment syndrome.
- Infection (osteomyelitis, rare with <24 hr dwell time).
- Fracture (if poor technique).
- Growth plate injury in kids (avoid with proper site selection).
Rookie mistakes:
- Not flushing after insertion → line won’t work.
- Choosing wrong site → through growth plate or too close to joint.
- Hesitating until too late.
Rookie Pearls
- 90 seconds or 2 IV attempts → move to IO.
- Proximal humerus = best flow in adults.
- Always flush hard — marrow is sticky.
- Secure device well — lines pop out if child moves.
- IO is safe for up to 24 hours, but convert to IV/central when possible.
Take-Home Message
Intraosseous access is a lifesaving skill every rookie must master.
- Don’t wait — place IO early if IV fails.
- Almost anything you can give IV, you can give IO.
- Complications are rare if technique is correct.
Remember: In a crashing patient, the wrong move is wasting time — grab the drill and save a life.
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