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Intraosseous (EZ I.O.)

Clinical Indications: Last Update 02/2009

    Patients where rapid, regular IV access is unavailable with any of the following:

    -Cardiac arrest.
    -Multisystem trauma with severe hypovolemia.
    -Severe dehydration with vascular collapse and/or loss of consciousness.
    -Respiratory failure / Respiratory arrest.


    -Fracture proximal to proposed intraosseous site.
    -History of Osteogenesis Imperfecta
    -Current or prior infection at proposed intraosseous site.
    -Previous intraosseous insertion or joint replacement at the selected site.


It is the responsibility of all personnel to adhere to the below procedures. The EZ-IO should be used as indicated. If a critical patient is in need of resuscitation (cardiac arrest, multisystem trauma with severe hypovolemia, severe dehydration with vascular collapse and/or loss of consciousness, respiratory distress/failure) & an IV cannot be established (two attempts- must be documented in PCR), the EZ-IO will be indicated. Although the diabetic patient who is unconscious could arguably fit this category, it is probably prudent to use other means for treatment (e.g. Glucagon). If there is no change in the patient’s status and further treatment is required, the EZ-IO should be considered for the administration of Dextrose. As with the administration of Dextrose, the possibility of infiltration of Dextrose through the EZ-IO is a concern and due caution should be used. If a situation presents where the EZ-IO is the first-line intervention, proper documentation must be noted in the PCR to justify the use of the EZ-IO without any IV attempts. Should a discrepancy arise, please reference protocols followed by contacting your EMS Chief.


1. Locate an insertion site:

Proximal Tibia-
The proximal tibia insertion site is approximately 2 cm below the patella and approximately 2 cm medial to the tibial tuberosity (depending on patient’s anatomy).

Proximal Humerus-
The proximal humerus insertion site is located directly on the most prominent aspect of the greater tubercle. Ensure that the patient’s hand is resting on the abdomen and that the elbow is adducted (close to the body). The hand may be pronated on the side of the body if unable to bend or move the arm. Slide thumb up the anterior shaft of the humerus until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm (depending on patient anatomy) above the surgical neck is the insertion site. This is the preferred site for patients who are responsive to pain. Once the insertion is completed secure the arm in place to prevent movement and accidental dislodgement of the IO catheter.

2. Clean the area with a providone-iodine swab.

3. Select the appropriate needle.

Small (pink) 15 mm needle: weight = 3-39 kg
Medium (blue) 25 mm needle: weight > 40 kg
Large (yellow) 45 mm needle: weight > 40 kg and patients with excessive tissue over insertion sites.
4. Remove the needle from the case. Push the needle onto the power driver, and make sure that is securely seated.

5. Remove and discard the needle set safety cap from the needle.

6. Insert the EZ-IO needle onto the tibial site at a 90-degree angle to the bone surface.

7. Gently power the needle set until it touches bone and then apply steady downward pressure.

8. Release the driver’s trigger until:

There is a sudden “give” or “pop”

The needle reaches the desired depth at 5mm, which is indicated on the needle by the black line.
9. Remove the power driver and needle stylet.

10. Confirm that the catheter is stable and secure with EZ-Stabilizer.

11. Use 10 ml of normal saline to flush the EZ-Connect extension set and then attach to exposed luer lock hub of the needle.

12. Pull back on the syringe to aspirate blood, then flush with 10 ml of normal saline under 5 seconds. Some patients may require more than one 10 ml flush.

13. If the route is patent, disconnect 10 ml syringe from EZ-Connect extension set.

14. Connect primed EZ-Connect extension set to primed IV tubing.

15. Attach a pressure infuser.

16. Following the administration of any IO medications, flush the IO line with 10 ml of IV fluid.

17. Secure the site and attach the wrist label to the patient’s hand.

11. You may administer 10 to 20 mg (1 to 2 cc) of 2% Lidocaine in adult patients who experience infusion-related pain. This may be repeated prn to a maximum of 60 mg (6 cc).

12. Following the administration of any IO medications, flush the IO line with 10 cc of IV fluid.

13. Document the procedure, time, and result (success) on/with the patient care report (PCR).

Competency Based Skill Requirements:

    Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. Any questions or for changes and updates contact your Training Bureau

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