Intraosseous cannulation - how to insert an intraosseous line

| In Articles | 15th July 2020

Intraosseous cannulation is a quick needle insertion, a relatively safe technique, used to gain rapid vascular access in critical situations. It utilises the marrow space of long bones as a ''non-collapsible vein'' and facilitates rapid absorption of administered emergency drugs and fluids into the systemic circulation. Aspirated blood may also be used to check haemoglobin, electrolytes, glucose, blood cultures and cross match.


  • Establishment of immediate vascular access during cardiac arrest (recommended route)
  • Establishment of vascular access during life-threatening situations such as shock, when other methods of venous access have been unsuccessful or take longer than 90 seconds


  • Previous attempts in the same bone (risk of extravasation through previous puncture site)
  • Recent bone fracture or bones proximal to site of insertion
  • Other significant proximal injury such as vascular damage
  • Osteoporosis, osteogenesis imperfecta
  • Overlying cellulitis, burn at site of insertion


  • Alcohol swabs
  • 18 gauge needle with trocar (at least 1.5cm long) such as Cook or appropriately sized EZ-IO needle with. battery operated drill
  • Bone injection guns are also used internationally
  • 20-50 ml syringe ± 3 way tap
  • Infusion fluid
Intraosseous cook needle
Cook needle
Bone injection gun - Intraosseous cannulation
Bone injection gun
Intraosseous EZ-IO needles
EZ-IO needles
3 way tap -Intraosseous cannulation
3 way tap


  • Proximal tibia - antero-medial surface 1-3 cm below tibial tuberosity (age dependent)
  • Distal tibia - 1-2 cm above (proximal to) medial malleolus halfway between anterior and posterior surfaces
  • Distal femur - anterlo-lateral surface 3 cm above the lateral condyle
  • Proximal humerus (adults)
  • Superior iliac crest (adults)


  • Identify the site of insertion
  • Clean skin
  • Local anaesthetic if the patient is conscious
  • Insert needle at 90 degrees to the skin
  • Cook needle: advance with a drilling motion (back-forward twisting + pressure) until a ''give'' is felt as the cortex is penetrated
  • Remove trocar
  • EZ-IO needle: advance needle + drill at insertion site using driver. Only gentle pressure is required. Cease drilling when a ''give'' is felt. Stabilise needle and remove drill. Unscrew to remove stylet from needle. Attach EZ-IO connection tubing.
  • Attach to a syringe and aspirate to confirm intramedullary position (and obtain samples as required). Aspiration is not always possible and a 0.9% saline flush may be adequate to confirm position. Observe for extravasation!
  • Attach to 20-50 ml syringe and administer infusion fluid as boluses. A 3 way tap attached to a giving set may facilitate this but fluid must be infused under pressure (usually manually)
  • Secure IO to skin to avoid accidental displacement and monitor for extravasation
  • Establish more definitive access when able

It is not recommended to perform arterial blood gas analysis on an intraosseous specimen because aspirated marrow in the specimen may have a deleterious effect on the blood gas machine!


  • Extravasation of infusion fluid/drugs - may occur with incorrect placement or movement of the needle or with penetration through both cortices of the bone
  • Compartment syndrome (increased pressure) - may develop with fluid extravasation or leak, avoid by monitoring!
  • Infection: osteomyelitis, septicaemia, cellulitis, subcutaneous abscess - minimise risk by removing intraosseous line when other stable vascular access is obtained!
  • Fracture and damage to growth plate - may occur if the patient has an underlying bone disorder or rarely if a needle that is too large is used/ incorrectly angled at insertion/wrong site is chosen
  • Local hematoma and skin necrosis
  • Fat and bone microemboli (tiny emboli)