Intraosseous (IO) Device

What Is It, Risks and Benefits, and More

Author: Anna Hernández, MD

Editors: Alyssa Haag, Ian Mannarino, MD, MBA, Kelsey LaFayette, DNP

Illustrator: Jessica Reynolds, MS

Copyeditor: David G. Walker

What is an intraosseous (IO) device?

An intraosseous (IO) device is a life-saving tool used to provide rapid vascular access in emergency situations where intravenous (IV) access cannot be obtained or is likely to delay treatment. 

The IO device consists of a hollow-bore needle that is placed through the cortical bone and into the medullary canal with the aid of an assisting device. The medullary canal is the inner cavity of long bones that contains the bone marrow, which is the site of blood cell production. This area of the bone is filled with a rich network of capillaries that are connected to the venous circulation through the emissary and nutritious veins. Unlike blood vessels, the bone marrow does not collapse in states of cardiovascular shock, so it can be used for the infusion of medications and fluids during resuscitation.

All medications, fluids, and blood products normally administered intravenously can also be given via the IO route. The intraosseous infusion rate is similar to that of an IV line; however, it will vary depending on the device used, the size of the needle, the insertion site, and the age of the individual. 

Insertion points for IO devices.

What are indications for an IO device?

According to the American Heart Association (AHA) and European Resuscitation Council (ERC) guidelines, the IO route is recommended as an alternative vascular access when, after 60 seconds, it has not been possible to place an intravenous line in either children or adults. Most commonly, the intraosseous route is used in emergency medicine situations, such as cardiac arrest, as well as in cases of severe shock, extensive burns, status epilepticus, multiple traumatic injuries, or an altered level of consciousness. 

This procedure is faster than central venous line placement and can be done without interrupting cardiopulmonary resuscitation (CPR). It is also easy to learn and has a high success rate on first attempts, making it extremely useful in prehospital emergency care. 

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What are the insertion sites of an IO device?

Generally, IO devices are placed at the proximal and distal ends of long bones where the cortical bone is thinner and there is more spongy bone present. 

In adults, the preferred sites of insertion include the proximal humerus, the proximal and distal tibia, the sternum, and the iliac crest. The proximal humerus is usually the first choice in adults because it offers higher infusion rates and less pain on insertion. The sternum provides a rapid access to the central venous circulation; however, its location interferes with CPR since cardiac massage cannot be performed.

In children, the preferred sites are the distal femur or the proximal and distal tibia, which are closer to the skin and easy to locate. In newborns and children under six years old, the proximal tibia is preferred, while the distal tibia is usually preferred in children over six years old. At the proximal tibia, the insertion site may be located by placing a finger one centimeter below the tibial tuberosity and then sliding the finger one centimeter medially, while the site of puncture for the distal tibia is two centimeters above the medial malleolus. In infants and young children, the IO device can also be placed in the distal femur, two to three centimeters above the patella, in the midline.

How is an IO device placed?

Several devices may be used for obtaining IO access, and they are classified as manual or automatic insertion devices. 

The most common manual devices include the Cook Dieckmann needle and the First Access for Shock and Trauma (FAST-1) device, which is specifically designed for IO insertion on the manubrium of the sternum. Manual devices insert the needle into the chosen site by using manual pressure. Conversely, automatic insertion devices use either a gun (e.g., Bone Injection Gun, or BIG) or a battery-powered drill (e.g., EZ-IO device) to push the needle through the cortical bone. The bone injection gun is available in two sizes, one for newborns and children up to 12 years of age and another for older children and adults. The EZ-IO device comes with three different lengths of IO needles to be used based on the weight of the individual. 

In all cases, the needle is placed perpendicular to the bone ensuring the growth plate is avoided in children. The bone injection gun works by pressing a trigger mechanism that releases the needle, while the EZ-IO device requires positioning the drill on top of the cortical bone and then activating the device until there is a “pop” or loss of resistance and the needle locks into place. If using a manual needle, it should be twisted firmly by applying pressure until a loss of resistance is felt. At this point, the needle shouldn’t be advanced anymore due to the risk of being pushed too deeply into the bone. Once the needle is in the bone marrow cavity, it should stand upright without support and there should be a return of blood when aspirating with a syringe.

Because the medullary cavity offers some resistance to the infusion of medications and fluids, it is necessary to perform a wash with saline before administering any treatment. In individuals who are awake, intramedullary anesthesia with lidocaine is recommended to relieve the pain. Medications administered via the IO route should be followed by a 5 to 10 mL flush of saline, and fluids need to be infused under pressure (e.g., with an infusion pump or pressure infusion bag) as gravity is insufficient to drive fluids through an IO line.

If swelling is observed at any time, the device should be removed and placed in another location. To remove the IO line, the needle is held by grasping the shaft while pulling up gently with a twisting motion until it is removed. It is important to avoid rocking the needle side to side which may bend it and enlarge the access hole in the bone. 

What are the benefits and risks of an IO device?

The main benefit of using an IO device is that it provides rapid vascular access in emergency situations, which can usually be obtained in less than one minute by trained personnel. In addition, the anatomical landmarks used to guide insertion sites are easily recognizable, resulting in a high rate of success when performing the technique. Because it is a non-collapsible cavity, the bone marrow can be used to infuse medications, fluids, and blood products in situations of severe shock or cardiac arrest as well as to obtain blood samples for laboratory testing. 

On the other hand, it is important to note that the IO access is meant to be a temporary venous access, and IO lines should be removed as soon as another venous access is obtained or within a maximum of 24 hours of insertion due to an increased risk of infection. Contraindications for the use of an IO device include insertion at sites with previous IO attempts or fractures of the bone and infection of the bone or surrounding tissues. This procedure should also be avoided in individuals with osteoporosis or prosthetic joints near the insertion site.

Finally, complications from the technique are generally rare but may include extravasation of fluid or medications, necrosis of the surrounding tissues, fractures or lesions on the growth plate in children, fat embolism, and infection of the insertion site. A severe complication is compartment syndrome, which occurs when increased pressure inside the limb causes decreased blood flow to the muscles and nerves, resulting in tissue damage. 

What are the most important facts to know about intraosseous (IO) devices?

The intraosseous (IO) device is a life-saving tool used to provide rapid vascular access in emergency situations. It is a safe and effective technique for infusing medications, fluids, and blood products in critically-ill individuals who do not have a peripheral IV line. In adults, IO devices are inserted in the proximal humerus or the proximal tibia; whereas in children, they are commonly placed in the proximal or distal tibia, depending on their age. There are several IO devices that can be used, the most common being the bone injection gun (BIG) and the EZ-IO device. The IO access should be removed within a maximum of 24 hours of insertion due to an increased risk of infection. Complications from the technique are rare and may include infection of the bone or surrounding tissue, fat embolism, fractures, extravasation, and compartment syndrome.

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Related links

Advanced cardiac life support (ACLS): Clinical practice
Anatomy of the leg
Bones of the upper limb

Resources for research and reference

Astasio-Picado Á, Cobos-Moreno P, Gómez-Martín B, Zabala-Baños MDC, Aranda-Martín C. Clinical management of intraosseous access in adults in critical situations for health professionals. Healthcare (Basel). 2022;10(2):367. doi:10.3390/healthcare10020367 

Day MW. Intraosseous Devices. Elsevier. 

Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18_suppl_3):S876-S908. doi:10.1161/circulationaha.110.971101

Luck RP, Haines C, Mull CC. Intraosseous access. J Emerg Med. 2010;39(4):468-475. doi:10.1016/j.jemermed.2009.04.054  

Lee PMJ, Lee C, Rattner P, Wu X, Gershengorn H, Acquah S. Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies. Crit Care Med. 2015;43(6):1233-1238. doi:10.1097/ccm.0000000000000942

Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardiovascular life support: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18_suppl_3):S719-767. doi:10.1161/circulationaha.110.970988