Intraosseous Vascular Access

E-Learning Resource
This package should be completed in conjunction with:
• Knowledge of the Paediatric Surviving Sepsis Guideline
• IO insertion skill stations (RCH simulation program &
skills lab)

Disclaimer:
This learning package has been developed by The Royal Children's Hospital. The information contained in this package is intended for the use of healthcare
professionals only. The Royal Children's Hospital does not accept any responsibility, and will not be liable for, any inaccuracies, omissions, information perceived as
misleading, or the success of any treatment regimen detailed in this package. Education packages may not be reproduced without permission.
Introduction
This learning resource has five components:
1. Before you start - reflection activity
2. Read and Learn
• Indications for insertion of an IO needle
• Safe insertion of an IO needle
• Risks and complications of IO needle insertion
• Which drugs and fluids can be administered through
an IO needle
3. Practical tips
4. Patient safety tips
5. Resource page should you want further information
Before you start
You are involved in the emergency resuscitation of a child
who has presented with probable meningococcal sepsis.

Two senior doctors are trying to get IV access (to

administer antibiotics and volume) but have been
unsuccessful and minutes are passing.

• Would you speak up and suggest an IO should be

inserted?
• Are you confident to do the procedure?
Indications for IO

IO line placement should be considered in

any emergency situation requiring
administration of fluids or drugs where
vascular access has not rapidly been
obtained (2 attempts or >90 seconds)
 Indications for IO

To gain emergency vascular access in

 Cardiac Arrest
 Deteriorating child
 Hemodynamic instability
 Respiratory compromise
 Altered level of consciousness
 Trauma
Thousands of small veins lead from the medullary space to the central circulation
Safe insertion of an IO needle
Equipment:
• Non sterile gloves
• Alcohol swab or dressing pack with
Chlorhexadine skin preparation
• EZ-IO driver and appropriate sized
needle Designed for 1000 human
insertions
• 5ml & 20ml syringe
• Infusion fluid
Prepare Equipment

EZ-IO Driver EZ-IO Needle EZ-Connect

 Prepare Equipment

Length and color are the only differences

between paediatric & adult needle sets
 Identify site

IO access sites for pediatric patient

 Proximal Tibial Anatomy

IO should be inserted 2 cm below tibial tuberosity

(away from growth plate)
Proximal Tibial Anatomy
Safe insertion of an IO needle
• Universal precautions
• Clean skin at insertion site
• Choose appropriate sized needle
• Attach needle to driver (magnetic)
• Hold needle & driver at 90o to skin and
push needle through skin until bone is
felt (without engaging driver)
Safe insertion of an IO needle
• Engage EZ-IO driver to advance needle
until there is a give / loss of resistance
• Detach driver (magnetic)
• Unscrew trochar
• Attach 5 ml syringe and aspirate
(Aspirate from marrow can be used to check glucose & provide
blood cultures, notify lab of BM specimen if sending any other
blood tests)

• Flush to confirm correct position

• Prime & attach EZ-IO connect
 Complications of IO
Extravasation of fluid or
medication
Compartment syndrome
Pain -associated with infusion
Osteomyelitis
Growth plate injury
Minor fractures
Contraindications for IO
Fracture of bone above IO site
Burn at or above insertion site
Cellulitis at insertion site
Osteogenesis imperfect
Osteopetrosis
Inability to locate landmarks or
excessive tissue
Complications of IO - pain

Minimal pain associated with

insertion of EZ-IO
• fast insertion speed
• small insertion site
• vast majority of awake patients
can tolerate insertion without
local anesthetic.

Infusion pain can be severe

• visceral in nature
• diffuse
• can evoke nausea
Which drugs & fluids can be given

All resuscitation drugs, fluids and blood

products can be administered through an IO
 Practical Tips
Due to resistance - fluids & drugs need
to be PUSHED through an IO

Patient Safety Tips

IO access provides emergency vascular
access. As soon as possible definitive
venous access should be obtained & IO
removed
Resources for additional reading

• Surviving Sepsis Campaign

• Surviving Sepsis – Special considerations in Paediatrics
• Insertion of Cooks IO needle (u-tube video)
• Insertion of EZ-IO in an adult (u-tube video)