Intraosseous Line

Choose Needle length (15, 25, 45mm) based on soft tissue thickness [Yellow for fat!]


  • Fracture/trauma
  • Previous IO attempt on same bone <48h
  • Overlying infection
  • Proximal circulatory compromize
  • Site specific: Inability to immobilize site (eg. unable to keep patient arm on chest due to chest compressions)


  • Proximal Tibia (children)
    • Immobilize leg
    • Identify tibial tuberosity and move onto tibial plateau:
      • Children move 2cm inferior and 1cm medial
      • Adults move 1cm inferior and 2cm medial
    • Insert 90 degrees (perpendicular) to bony plane
  • Proximal Humerus (adults)
    • Immobilize arm on chest (internal rotation)
      • Alternative: Extend elbow along side of body and exaggerated hyperpronation/internal rotation of arm
    • Avoid biccipital groove/tendon
    • On anterolateral shoulder identify surgical neck of humerus
    • Insertion site 1cm above neck of humerus
    • Insert 90 degrees (perpendicular) to skin
  • Other options: distal tibia (1-2cm superior to medial malleolus), distal femur (1-2cm above patella in young children)


  • Consider local anesthesia for skin/periosteum
  • Consider cleaning site and let dry
  • Stabilize site (secure limbs well)
  • Insert needle through soft tissue until hits bone
  • Power drill with light and steady pressure until feel "give/pop"
    • Do not push, allow drill to do the work
    • Careful in children, as often IO inserted through bone
  • Remove stylet (by turning counter-clockwise)
  • Consider analgesia (2-2-2) = 2mL of 2% lidocaine mixed into 10mL NS flush syringe, wait 2 minutes for analgesia, may repeat twice PRN
  • Flush slowly to prevent fat embolism
  • Secure catheter hub with stabilizer or stacked gauze and tape
    • Dislodgement can cause leak

Confirm placement

  • Firm placement of needle in bone
  • Blood in stylet
  • Return of bone marrow
  • Smooth fluid flush
  • Watch for extravasation
  • Check flow while squeezing soft tissue around site of placement (to check if infusing in soft tissue)
  • Consider POCUS

If failure, place another IO (success-pass success rate almost 100%)!

Removing the IO needle

  • Use a syringe with a luer lock to screw on IO needle
  • Holding limb in one hand and syringe in other can pull out as you rotate clockwise