Intra Osseous (IO) Access

• Antiseptic solution for cleaning the skin (chlorhexidine, alcohol, or povidone-iodine)
• Appropriate needle for the patient’s age and size
• Gloves
• IO mechanical device and extension piece
• Syringe and flush solution
• Securement dressing

• Bone growth abnormalities can result from damage to the epiphyseal growth plate before development.

The proximal tibia site, which is the preferred site, is 1 to 3 cm below and medial to the tibial tuberosity.
The proximal humerus site is approximately 1 to 2 cm above the surgical neck.
The distal tibia site is 1 to 2 cm proximal to the most prominent point of the medial malleolus at the longitudinal midline of the tibia.
The femur site is just proximal to the patella, approximately 1 to 2 cm medial to the midline.

1. Gather equipment, perform hand hygiene
2. Use landmarks to palpate the bone and determine exact insertion site avoiding the epiphyseal growth plate
3. Position the patient to ensure optimal access to the targeted bone. Consider placing targeted bone over a firm surface
4. Stabilize, position, and support the targeted limb taking care to avoid placing hand directly behind the insertion site
5. Perform hand hygiene and don gloves
6. Cleanse the area with antiseptic and maintain no-touch technique
7. Insert IO Access (See Instructions below)
8. Attach a syringe and gently aspirate. Placement confirmed with the presence of bone marrow
9. Attach a primed extension piece to the IO needle
10. Attach a syringe to the extension piece and administer a rapid 0.9% sodium chloride solution flush
11. Secure the needle with stabilization device or tape and gauze dressing

1. Connect the appropriate sized needle to the power driver
2. Remove the needle safety cap and position the driver at a 90-degree angle for tibial and femur insertion and at a 45-degree angle for humerus insertion into the bone
3. Puncture skin allowing the tip of the needle to touch the bone
4. Activate the power driver and drill the needle into the bone until a release of resistance is felt.

5. Remove the driver, stabilize the needle hub while turning the stylet counterclockwise and remove the needle hub.

   EZ-IO Insertion Video:

   Remote video URL

1. Adjust the trocar depth based on the age, weight and manufacturers instructions
2. Position the barrel of the B.I.G. at the insertion site at a 90 degree angle using the non-dominant hand. While maintaining patient contact, squeeze and pull the red safety latch out with the dominant hand
3. While firmly holding the device in place with the non-dominant hand, use the dominant hand to deploy the needle by grasping under the wings of the device with two fingers and steadily and gently pressing the palm against the top of the device. A ‘pop’ will be heard when the needle is successfully deployed. The kickback of the device can push the hand back and prevent the needle from entering the bone if it is not held firmly against the extremity.
4. Remove the housing of the B.I.G. by carefully pulling upward with a slight side-to-side movement to clear the stylet trocar.
5. Remove the trocar from the center of the needle by pulling and rotating upward. The cannula will remain in the bone.

B.I.G Insertion Video

Continuously monitor for complications:

• Perfusion: Monitor for perfusion distal to IO site
• Extravasation: Monitor insertion site for leakage and the anterior and posterior surfaces. Measure leg circumference distal to the insertion site every 4 hours or as clinically indicated.
• Compartment Syndrome: Monitor for increased swelling and firmness of extremity.
• Fat Embolism: May present as pulmonary (shortness of breath, hypoxemia), neurological (agitation, headache), or dermatological (petechial rash)
• Bone Injury: Bone fractures may occur with IO insertion and may be detected on clinical exam or x-ray