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Intravascular/Interosseous Access and Fluid Resuscitation


Questions and Answers

Case: You arrive on scene to find an 80-year-old woman who appears to be in obvious distress. Family reports that she has had a fever for several days as well as a productive cough and shortness of breath. Vitals are blood pressure (BP) 80/40, heart rate (HR) 130, respiratory rate (RR) 26, and SPO 2 91% on room air. You want to initiate a fluid bolus to treat hypotension associated with suspected septic shock. Unfortunately, after two attempts, you have been unable to place a peripheral IV.

1

What is an alternative form of access that can be employed?

Peripheral venous cannulation (PIV) and intraosseous (IO) access are the most common ways that access is established. Peripheral access is typically the primary form of venous access, with IO access being second line. Central venous access in the EMS setting is rare. In some cases, patients may have ports or preexisting central lines that can be accessed when an emergent need is present.

2

What are the flow rates that can be achieved by IO access?

The EZ-IO manufactured by Teleflex is one IO access device that is in common use. Research has shown that the humeral mean flow rate is about 5 L per hour and tibial flow rate is about 1 L per hour. These flow rates were achieved using a pressure bag system. Using pressure infusion is key to achieving adequate flow using an intraosseous line. Per the manufacturer of the EZ-IO, a rapid flush is also needed to achieve high flow rates. This helps clear the marrow from around the insertion site.

3

What are the indications for IO access over PIV access?

Indications for IO access include failed PIV access and/or the need for rapid access for resuscitation. Often, cardiac arrest can be an indication to use IO as a first-line option as it can often be faster to obtain than a PIV.

4

What are some contraindications to IO access?

Contraindications to IO access include:

  • Acute fracture of the selected bone;

  • Overlying infection at the insertion site;

  • Any previous attempt in the same bone within 48 hours;

  • Inability to identify landmarks; and

  • Prosthetic bone or joint at insertion site.

Contraindications at any one site do not preclude attempts at a different site. Osteoporosis or osteogenesis imperfecta and more proximal fractures are also relative contraindications.

5

Can all medications be given via the IO route?

Yes, all medications that can be given via the intravenous route are appropriate for IO infusion, including vasopressors and blood products.

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