Procedure 41 — Venous Access: Intraosseous Access

Name three clinical indications for intraosseous access.

Cardiac arrest, multisystem trauma with severe hypovolemia, or a significantly-burned patient with no IV access.

Name two more clinical indications for intraosseous access.

Severe dehydration with vascular collapse and/or loss of consciousness, and respiratory failure/respiratory arrest.

What general condition also indicates intraosseous access?

Any other immediately life-threatening, pre-arrest clinical condition in which IV access is unobtainable.

What underlying requirement applies to all IO access indications?

Rapid, regular IV access is unavailable.

What fracture location is a contraindication for IO access?

A fracture proximal to the proposed IO site.

What bone condition is a contraindication for IO access?

A history of Osteogenesis Imperfecta.

What infection status is a contraindication for IO access?

Current or prior infection at the proposed IO site.

What recent procedure is a contraindication for IO access at the same site?

Previous intraosseous insertion within 48 hours, or joint replacement at that site.

What should be gathered before beginning IO access?

Personal protective equipment, such as gloves and eye protection.

What landmark is used to locate the proximal tibia IO insertion site?

The anteromedial aspect of the proximal tibia, the bony prominence below the kneecap.

Where exactly is the proximal tibia IO insertion location relative to that landmark?

A flattened area 1-2 cm (2 finger widths) below it.

What minimum patient weight is required for proximal humerus IO access?

Greater than 40 kg.

What landmark is used to locate the proximal humerus IO insertion site?

The lateral aspect of the humerus, 2 cm distal to the greater tuberosity.

What needle length must be used for the proximal humerus IO site?

A 45mm IO needle.

What is used to prep the IO insertion site?

Povidone-iodine.

What should be checked on the BD IO driver device before use?

That it has at least two LED lights on.

At what angle is the IO needle held against the bone during insertion?

90 degrees.

What must be stabilized while holding the IO needle against the bone?

The body part.

What is done to the driver during IO needle insertion?

Power it until the drill stops, or until a "pop" or "give" is felt indicating loss of resistance.

What should not be done once loss of resistance is felt during IO insertion?

Advance the needle any further.

What is the smallest IO needle size, and what is it used for?

15mm, intended only for neonatal patients at the anteromedial aspect of the proximal tibia.

Where is the IO needle disposed of after removal?

An approved sharps container.

What volume of saline is used to clear the lumen of an IO needle after placement?

At least 5 mL.

What is attached and adjusted after clearing the IO needle lumen?

The primed IV line, adjusting the flow rate.

What may assist with achieving desired flow rates through an IO line?

A pressure bag.

How is the IO needle stabilized after placement?

With the stabilizer device.

What is the maximum adult IO Lidocaine dose for infusion-related pain?

1 mg/kg, maximum 50 mg.

Name three conditions that must be absent before administering adult IO Lidocaine anesthesia.

Allergies to lidocaine, bradycardia, and AV heart blocks on the ECG.

What is the maximum pediatric IO Lidocaine dose for infusion-related pain?

0.5 mg/kg, maximum 40 mg.

What conditions must be assured absent before administering pediatric IO Lidocaine anesthesia?

No drug allergies to lidocaine, bradycardia, or AV heart blocks on the ECG.

How long should IO lidocaine be allowed to take effect before flushing or infusing further in a conscious patient?

At least 60 seconds.

What volume of saline is used to flush an adult IO line after each medication infusion?

10 mL of normal saline.

What volume of saline is used to flush a pediatric IO line after each medication infusion?

5 mL of normal saline.

What must be documented after IO access?

The procedure, time, and result on the PCR.

What provider levels can perform intraosseous access?

EMT-A, EMT-B (with training), and EMT-P.