Intraosseous Vascular Access

E-Learning Resourced
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
 Contraindications for
Complications of IO
IO
Extravasation of fluid or Fracture of bone above IO
medication site
Burn at or above insertion
Compartment syndrome
site
Pain -associated with
Cellulitis at insertion site
infusion
Osteomyelitis Osteogenesis imperfect
Growth plate injury Osteopetrosis
Inability to locate landmarks
Minor fractures
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)
Certificate of Completion
Kidanemariam Tamrat

has completed the eLearning module

“Interosseous insertion”
on 29/11/23