PROCEDURE
85 Intraosseous Devices
Michael W. Day
PURPO SE: Intraosseous access is indicated when intravenous (IV) access cannot
be obtained or cannot be obtained in a timely manner and access to venous
circulation is needed for the administration of medications or fluids.
PREREQUISITE NURSING
KNOWLEDGE
• Intraosseous (IO) access is a safe and reliable access point
into the noncollapsible marrow cavity that allows direct
access to the venous circulation.6–8 Indications for IO
access include status epilepticus, extensive burns, morbid
obesity (which may prevent peripheral or central line
placement),6 sepsis, and multiple traumatic injuries.8
• IO is significantly faster than central venous placement
during actual resuscitation15 and in simulation.19
• Use of IO devices may decrease the use of emergency
femoral access, with its attendant complications.8 “Despite
recommendations from a number of specialty societies on
the use of IO access when IV access has failed in emergent
patients, IO access appears to be an underutilized access
tool in the hospital ED (emergency departments).”21
• The Volkmann’s canals that are located throughout the
bone connect with the medullary canal and the blood
vessels of the periosteum (Fig. 85-1). When medications
and fluids are introduced into the medullary canal, they
flow through the vascular plexi directly into the vascular
system.6,7
• Mechanical insertion devices are available for insertion of
IO needles.6 These devices include the bone injection gun
(BIG; Waismed, a Persys Medical Co, Houston, TX; Fig.
85-2), the FASTResponder adult IO infusion system
(Pyng Medical Corp, Vancouver, BC, Canada, Fig. 85-3),
and the EZ-IO (Teleflex, Shavano Park, TX; Fig. 85-4).
These three devices are approved by the US Food and
Drug Administration (FDA) for IO access in adult patients.
Two of the devices (BIG, Arrow EZ-IO) use a specially
designed needle with a stylet or trocar. The third device
(FASTResponder) uses a metal-tipped plastic catheter.
The attributes of the three devices of this procedure are
summarized in Table 85-1.
• In adults, the available IO access sites, depending on the
specific device and following each manufacturer ’s guide-
lines,3 include the following:
❖ Tibial plateau: 1 to 2 cm distal to the tibial tuberosity
❖ Distal tibia: 1 to 2 cm above the medial malleolus
❖ Manubrium: 1.5 cm below the sternal notch
❖ Greater tubercle of the proximal humerus
• A recent study using the EZ-IO device found that there
was a significantly higher success rate with proximal tibial
compared with humeral placement.18
748
• IO blood can be used for many laboratory tests, including
typing and screening, electrolyte values, chemistries,
blood gas values, drug levels, and hemoglobin levels.7,20
❖ However, specimen samples from the marrow have a
lower correlation to serum levels after 30 minutes of
resuscitation.4
20
❖ IO samples may be used for point-of-care testing.
❖ In addition, drawing of blood from an IO device may
not be recommended by specific manufacturers and has
the potential of occluding the device.11
• The onset of action for medications is similar to that of
IV medications.7,8 However, administration via the IO
route may result in lower serum concentrations versus the
IV route for the following medications: ceftriaxone, chlor-
amphenicol, phenytoin, tobramycin, and vancomycin.4
• Marrow-toxic medications should not be infused via the
IO route.13
• There is some research to support the use of IO devices
for IV contrast.1,12
• All resuscitation medications, isotonic fluids, and blood
products may be given via the IO route5; however, myo-
necrosis has been reported with the infusion of hypertonic
saline solution via the IO route.17
• Medications administered via the IO route should be fol-
lowed by a 5- to 10-mL flush of normal saline solution.
Resistance to the manual flush will be felt but does NOT
indicate incorrect placement. If swelling or infiltration is
observed, remove the device and attempt IO access in
another bone.6,7
• Fluids running into an IO line should be administered with
a pressure bag inflated to 300 mm Hg because the pressure
needed to push the fluid into the bone marrow may exceed
that of volumetric IV pumps. Flow rates can be managed
with the IV tubing roller clamp.6
• Complications of IO access include compartment syn-
drome, osteomyelitis, fracture, extravasation,5 necrosis,5,10
and infection.8
• A syringe should not be attached directly to the hub of the
IO needle because it could cause dislodgment, increase
the size of the hole, and cause extravasation or loss of the
IO site. To extend access to the IO needle, attach extension
tubing to the hub of the IO needle and secure it to the skin.
Some device insertion kits come with extension tubing.
• Absolute contraindications to attempting an IO access
include previous attempts or fractures of the targeted
bone.
 85 Intraosseous Devices 749

Figure 85-1 Intraosseous circulation. (From Day MW: Intraosseous devices for intravenous
access in adult trauma patients, Crit Care Nurs 31[2]:76–90.)

Figure 85-2 Bone injection gun (BIG; adult). (From Day MW:
Intraosseous devices for intravenous access in adult trauma
patients, Crit Care Nurs 31[2]:76–90.)

Figure 85-4 EZ-IO power driver. (From Day MW: Intraosseous

devices for intravenous access in adult trauma patients, Crit Care
Nurs 31[2]:76–90.)

• Relative contraindications to IO access include infection

• IO access in obese patients may be more difficult. The
Figure 85-3 The FASTResponder. (Courtesy Pyng Medical,
Richmond, British Columbia.)
at the access site, artificial joint replacement at the inser-
tion site,8 fractures above the insertion site, inability to
locate landmarks,5 and bone disorders, such as osteoporo-
sis and osteogenesis imperfecta. Another relative contra-
indication to the FASTResponder is skin damage at the
insertion site, which may preclude the adherence of the
target foot patch used to secure the device.
Arrow EZ-IO has a needle set specifically designed for
the patient with “excessive tissue” at the insertion site.
750 Unit II Cardiovascular System

TABLE 85-1 Intraosseous (IO) Device Comparison Table

Big EZ-IO FASTResponder
Insertion sites • Proximal tibia • Proximal tibia • Manubrium
• Proximal humerus • Distal tibia
• Proximal humerus
Insertion process • Activated by manual pressure • Battery-operated power driver • Activated by manual pressure
Advantages • Small • Color coded, weight-based needle • Small
• Color coded (blue, adult; red, sets (PD, 3–39 kg; AD, >40 kg; LD, • Lightweight
pediatric) >40 kg and “excess tissue” over • Single insertion site
• Lightweight insertion site) (consistent site = less
• Multiple insertion sites (total of four) • Multiple insertion sites (total of six) training)
Disadvantages • May cause “scatter” artifact in • Large device and packaging • No alternative insertion site
chest or cervical spine CT when • Requires visualization of needle skin • Requires two hands to exert
placed in humerus depth before insertion in bone pressure needed to activate
• May be overlooked during transport • May cause “scatter” artifact in chest the device
or transition from one level of care or cervical spine CT when placed in • May preclude use of a
to another humerus cervical collar (towel rolls
• May be overlooked during transport and taping the patient’s head
or transition from one level of care to to a backboard may be
another substituted)
Contraindications • Insertion in limbs with fractures • Insertion in limbs with fractures • Severe osteoporosis or other
• Insertion in limbs with prosthetic • Insertion in limbs with prosthetic bone pathology
joints near insertion site joints near insertion site • Inability to secure target
• Insertion at sites with previous IO • Insertion at sites with previous IO patch to skin over
attempt attempt manubrium (i.e., burns,
• Severe osteoporosis or other bone • Severe osteoporosis or other bone wounds, infection)
pathology pathology
• Infection present over insertion site • Infection present over insertion site
• Inability to identify pertinent • Inability to identify pertinent insertion
insertion landmarks landmarks
Removal • Grasp needle hub with safety latch • Attach syringe • Stabilize target foot
• Pull and twist • Pull and twist counterclockwise (if • Grasp infusion tube and pull
hub separates, grasp needle with it out perpendicular to the
large needle forceps, pull, and twist manubrium
counterclockwise)

Adapted from Day MW: Intraosseous devices for intravenous access in adult trauma patients, Crit Care Nurs 31(2):76–90, 2011.

• IO access is meant to be a temporary venous access; IO • Isotonic crystalloid fluid, as prescribed

lines should be removed as soon as other venous access • Two 5- to 10-mL syringes
is obtained or within 24 hours of insertion.8 • Prescribed medications
• Magnetic resonance imaging is not an option when an IO • Pressure bag for IV solution
device is present,8 whereas an IO humeral placement may • Dressing supplies
interfere with chest, low cervical, or high thoracic com- Additional equipment, to have available as needed, includes
puterized tomography (CT).6 the following:
• Sternal IO devices may interfere with the placement of a • Blood-specimen tubes
cervical collar in trauma patients, requiring alternative • 1% or 2% preservative free lidocaine without
methods to maintain cervical stabilization.6 epinephrine
• Sterile 2 × 2 gauze pads
EQUIPMENT • Large needle forceps

• Nonsterile gloves PATIENT AND FAMILY EDUCATION

• Antiseptic solution (e.g., 2% chlorhexidine-based
preparation) • If the clinical situation permits, explain to the patient and
• IO insertion device (follow manufacturer ’s guidelines for family the reason for the IO access. Rationale: Clarifica-
information that may be age or weight based) tion of information is an expressed patient need and helps
• Tape to diminish anxiety, enhance acceptance, and encourage
• IV tubing and extension tubing questions.
 85 Intraosseous Devices 751

• Describe the major steps of the procedure, including the
patient’s role in the procedure. Rationale: Explanation
decreases patient anxiety, enhances cooperation, provides
an opportunity for the patient to voice concerns, and pre-
vents accidental contamination of the sterile field and
equipment.
• Explain the expected outcomes of the procedure. Ratio-
nale: Explanation reduces anxiety and clarifies the dura-
tion and goals of IO access.
PATIENT ASSESSMENT AND
PREPARATION
Patient Assessment
• Assess the patient for fractures or infections at the inser-
tion site, for previous bone surgeries at the site, and for a
history of osteoporosis or fractures of the target bone.
Rationale: An alternate site should be accessed to avoid
possible complications associated with the previous
conditions.
• Obtain the patient’s baseline vital signs and cardiac
rhythm. Rationale: Baseline data facilitate the identifica-
tion of clinical problems and identify the urgency of
obtaining IO access.
• If possible, determine the patient’s allergy history (e.g.,
lidocaine, antiseptic solutions). Rationale: This assess-
ment decreases the risk for allergic reactions by avoiding
known allergenic products.
Patient Preparation
• Verify that the patient is the correct patient using two
identifiers. Rationale: Before performing a procedure, the
nurse should ensure the correct identification of the patient
for the intended intervention.
• Ensure that the patient and family understand preprocedural
teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previ-
ously taught information is evaluated and reinforced.
• Perform a preprocedure verification and time out, if non-
emergent. Rationale: Ensures patient safety.

Procedure for Intraosseous Access

Steps Rationale Special Considerations
1. HH
2. PE
3. Assist the patient to a position of Prepares the patient for the procedure
comfort for access of the and allows for optimal
appropriate insertion site. visualization.
4. Palpate the intended insertion Guides IO device placement.
site.
A. Proximal tibia:
i. Identify the tibial
tuberosity.
ii. Move 2 cm medially and
1 cm proximally.
B. Distal tibia:
i. Identify the medial
malleolus.
ii. Move two finger widths
proximally at the midline
of the medial aspect of the
leg.
C. Manubrium:
i. Identify the sternal notch.
ii. Align the target foot with
the sternal notch.
D. Humerus:
i. Identify the greater
tubercle.
ii. Move one finger width
lateral from the greater
tubercle.
5. Cleanse the intended site and Limits the introduction of potentially
surrounding area with antiseptic infectious skin flora into the
solution (e.g., 2% chlorhexidine- insertion site.
based preparation).
Procedure continues on following page
752 Unit II Cardiovascular System

Procedure for Intraosseous Access—Continued

Steps Rationale Special Considerations
6. For those devices placed in Prevents movement of the limb Ensure that the nondominant hand is
extremities, stabilize the insertion during insertion. NOT in line with IO placement to
site with the nondominant hand. prevent inadvertent injury.
7. FASTResponder9 insertion (see Inserts the IO device. Follow manufacturer ’s guidelines.
Fig. 85-3): It is critical that the FASTResponder
A. The FASTResponder is be held perpendicular to the
inserted into the manubrium. manubrium and not the patient’s
B. Place the patient in a flat, body.
supine position. Attempting to place the
C. Assume a position at the FASTResponder device with the
patient’s head. patient in a sitting position, from
D. Remove the locking pin and the patient’s side, or using one hand
pull away from the device; is NOT recommended because it
identify the sternal notch with may move the physician, advanced
the thumb of the nondominant practice nurse, or other healthcare
hand. professional away from
E. Align the target foot with the perpendicular to the manubrium.
sternal notch and press to Removing the locking pin exposes the
apply. adhesive surface of the target foot
F. Grasp the device with both and readies the device for insertion.
hands, with the thumbs side
by side.
G. Ensure that the device is
perpendicular with the
manubrium and NOT the
patient’s body.
H. Apply steady pressure until
the device is heard and felt to
deploy the infusion tube.
I. Stabilize the target foot with
the nondominant hand and
slowly withdraw the device
with the dominant hand, while
remaining perpendicular to the
manubrium.
J. Remove the antibuckle device
from the infusion tube.
K. After correct placement has
been confirmed, connect the
strain relief hook to the hook
on the target foot.
L. Remove covering from the
protective dome and apply
over the target foot and
infusion tube.
(Level M*)

*Level M: Manufacturer’s recommendations only.

 85 Intraosseous Devices 753

Procedure for Intraosseous Access—Continued

Steps Rationale Special Considerations
3
8. BIG insertion (see Fig. 85-2): Inserts the IO needle. The BIG device is color coded.
A. The BIG can be inserted into The adult device is blue.
the proximal tibia or the
humerus.
B. Palpate the appropriate
landmarks with the dominant
hand, and with the
nondominant hand place the
barrel of the BIG on the skin
perpendicular to the intended
insertion site.
C. With the dominant hand,
squeeze and remove the red
safety latch.
D. Grasp the “shoulders” of the
BIG with the fingers of the
dominant hand while the palm
presses down into the BIG
and deploys the needle and
trocar.
E. Remove the BIG and stabilize
the needle.
F. Remove the trocar from the
needle and secure the needle
to the skin by taping the red
safety latch around it.
(Level M*)
9. Arrow EZ-IO2 insertion (see Inserts the IO needle. Follow manufacturer ’s guidelines for
Fig. 85-4): selection of the size of the needle
A. The Arrow EZ-IO can be based on patient weight.
inserted into the proximal If the 5-mm mark is not visible, the
tibia, the distal tibia, or the needle is withdrawn and a larger
humerus. size is attached and advanced into
B. Connect the appropriately the insertion site.
sized needle to the power
driver (Fig. 85-5).
C. Palpate the appropriate
landmark.
D. Stabilize the limb and
advance the needle at a
90-degree angle through the
skin until the bone is felt.
E. When the 5-mm mark is
visible, apply steady, firm
pressure and activate the power
driver until the needle hub
contacts the skin or a sudden
decrease in resistance is noted.
F. Stabilize the needle and
remove the power driver.
G. Remove the stylet from the
needle by turning it
counterclockwise while
withdrawing it.
(Level M*)

*Level M: Manufacturer’s recommendations only.

Procedure continues on following page

754 Unit II Cardiovascular System
PD
AD
LD
Figure 85-5 EZ-IO needle sets. (From Day MW: Intraosseous devices for intravenous access in
adult trauma patients, Crit Care Nurs 31[2]:76–90.)
Procedure for Intraosseous Access—Continued
Steps
10. Secure the IO catheter or needle
as recommended by the
manufacturer.
(Level M*)
11. Apply a sterile, occlusive
dressing.
12. Confirm placement by:
A. Aspirating blood or marrow.
B. Flushing the needle with
10 mL of normal saline
solution.
13. Securely attach the tubing and
tape it to the patient’s skin.
14. Infuse IV fluids with a pressure
bag or manual pressure.
15. If the patient is alert, slowly
(over 60 seconds)8 infuse
lidocaine (without epinephrine)
into the IO device as prescribed.
*Level M: Manufacturer’s recommendations only.
Rationale
Prevents the needle from moving.
Promotes a sterile environment.
Verifies needle placement in the
marrow cavity.
Secures the tubing system.
IO lines often need pressure to ensure
adequate flow.
Promotes comfort.
Special Considerations
Follow institutional standards.
If blood specimens are needed, attach
a 5-mL syringe and aspirate bone
marrow and blood from the site.8,14
Aspiration of marrow may occlude
the IO device with bone.
Lack of marrow aspirate does not
indicate improper placement.8
Resistance to the manual flush will be
felt but does NOT indicate incorrect
placement.
If swelling or infiltration is observed,
remove the device and attempt IO
access in another bone.7
Care should be taken when
positioning and transferring the
patient to avoid dislodgment of the
IO device.
The resistance of fluid flow through
an IO may exceed the pressure
limits on infusion pumps.
The infusion of fluids and
medications can be painful to the
conscious patient.
 85 Intraosseous Devices 755

Procedure for Intraosseous Access—Continued

Steps Rationale Special Considerations
16. Administer prescribed Following medications with a saline Resistance to the manual flush will be
medications via the IO device solution flush ensures delivery of felt but does NOT indicate incorrect
and follow each medication with medication into the marrow cavity placement.
a 5–10-mL normal saline solution and blood vessels. If swelling or infiltration is observed,
flush as prescribed.16 (Level E*) remove the device and attempt IO
access in another bone.7
17. Remove PE and discard used Removes and safely discards used
supplies in appropriate supplies.
receptacles.
18. HH
Procedure for Removal of the Intraosseous Access
1. HH
2. PE
3. Replace the IO site within 24 IO access is a temporary access site. For minimization of the risk of
hours or as soon as venous access complications, the IO device should
is obtained. be removed as soon as alternate
vascular access is obtained or
within 24 hours.
4. Follow manufacturer ’s guidelines IO device is no longer needed. Follow manufacturer ’s guidelines.
for removal: Be sure to pull perpendicular to the
(Level M*) patient’s manubrium, not the
patient’s body.
A. FASTResponder9: Inspect the infusion tube upon
i. Remove the protective removal to ensure that the metal tip
dome and stabilize the has been removed.
target foot with the If the metal tip separates from the
nondominant hand. infusion tube, contact the physician.
ii. Grasp the infusion tube as
close as possible to the tip
and fold it around the
finger.
iii. Pull back in a steady
motion until the infusion
tube is removed.
B. BIG removal3:
i. Grasp the IO device hub
with the red safety latch.
ii. Simultaneously rotate and
withdraw the IO device.
C. Arrow EZ-IO removal2:
i. Attach a 5–10-mL syringe
to the hub of the IO
device.
ii. Stabilize the limb.
iii. Simultaneously rotate
clockwise and pull the IO
device out.
iv. If the hub separates from
the body of the IO device,
grasp the body with large
(8-inch) needle forceps and
simultaneously rotate the
body and pull to remove.6

*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to
support recommendations.
*Level M: Manufacturer’s recommendations only.

Procedure continues on following page

756 Unit II Cardiovascular System

Procedure for Intraosseous Access—Continued

Steps
5. Apply an occlusive, sterile
dressing to the site.
6. Remove PE and discard used
supplies in appropriate
receptacles.
7. HH
Rationale Special Considerations
Promotes a sterile environment.
Reduces the transmission of
microorganisms; Standard
Precautions. Safely remove sharp
objects.

Expected Outcomes Unexpected Outcomes

• Access to venous circulation for the administration of • Inability to infuse medications or fluids
medications and fluids • Infection
• The IO line remains patent • Extravasation
• The tip of the IO needle lies in the marrow cavity • Complications such as compartment syndrome,
• The insertion site, catheter, and systemic circulation fractures, osteomyelitis, and necrosis
remain free of infection • Pain

Patient Monitoring and Care

Steps
1. Observe for signs and symptoms
of infection.
2. Observe the IO insertion site for
signs and symptoms of
extravasation or compartment
syndrome.
3. Follow institutional standards for
assessing pain. Administer
analgesia as prescribed.
Rationale
Identifies possible complications.
A misplaced device or excessive
movement after insertion may lead
to a leakage of fluids outside of the
marrow cavity and can impair
circulation to the extremity.
Identifies need for pain interventions.
Reportable Conditions
These conditions should be reported if
they persist despite nursing
interventions.
• Edema around the site
• Pain, tenderness, or erythema
around the site
• Drainage from the site
• Increased temperature
• Elevated white blood cell count
• Increased circumference of the
extremity
• Increased pain in the extremity
• Change in extremity sensation,
temperature, or pulses
• Continued pain despite pain
interventions

Documentation
Documentation should include the following:
• Patient and family education
• Preprocedure verification and timeout
• Site of insertion
• Number of IO insertion attempts
• Sites of previous IO insertion attempts
• Brand of the IO device inserted and, if appropriate,
manufacturer ’s needle description
• Confirmation of IO needle placement
• Date and time of insertion
• Type and amount of anesthetic used
• Assessment of insertion site
• Method of securing the IO needle in place
• Problems encountered during or after the procedure
• Pain assessment, interventions, and effectiveness
• Vital signs and cardiac rhythm
• Date and time the IO device is removed
• Assessment of site after the IO device is removed
 85 Intraosseous Devices 757

References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.