Monday, June 10, 2024

EMS Medication Administration - Intraosseous (IO) Route

EMS providers should have comprehensive knowledge of intraosseous (IO) medication administration within their scope of practice to ensure patient safety and effective treatment. 

Here are the key points they should know:

1. Indications and Contraindications

  • Indications:
    • IO access is typically used when IV access is difficult or impossible, especially in emergencies.
    • Common scenarios include cardiac arrest, severe shock, trauma, and other situations requiring immediate vascular access.
  • Contraindications:
    • Fractures in the targeted bone
    • Previous orthopedic procedures at the insertion site
    • Infection at the insertion site
    • Osteoporosis or other bone abnormalities

2. Anatomy and Site Selection

  • Common IO Sites:
    • Proximal tibia
    • Distal tibia
    • Proximal humerus
    • Sternum (primarily in adults)
  • Site Selection Criteria:
    • Age of the patient
    • Accessibility of the site
    • Absence of contraindications like fractures or infections

3. IO Device Knowledge

  • Types of IO Devices: Familiarity with various IO devices such as manual needles, battery-powered devices (e.g., EZ-IO), and spring-loaded devices.
  • Device Operation: Understanding the specific operation, insertion technique, and maintenance of the IO device they are using.

4. Insertion Technique

  • Preparation:
    • Use of aseptic technique to prevent infection
    • Selection of appropriate needle size based on patient age and size
  • Insertion Steps:
    • Properly positioning the patient
    • Identifying the correct anatomical landmarks
    • Using correct insertion angle and depth
  • Confirmation of Placement:
    • Aspiration of bone marrow or blood
    • Easy flushing of saline without resistance
    • Securing the IO needle to prevent dislodgement

5. Medication Administration

  • Types of Medications: Most medications that can be given IV can also be administered IO, including fluids, blood products, antibiotics, and emergency medications.
  • Dosage and Rate:
    • Ensuring correct dosing similar to IV administration
    • Awareness of potential variations in absorption and onset of action
  • Flush Protocol: Flushing the IO line with saline to ensure patency and proper delivery of medications.

6. Complications and Management

  • Extravasation: Recognizing and managing extravasation (leakage of fluid into surrounding tissues).
  • Infection: Preventing and identifying signs of infection at the insertion site.
  • Compartment Syndrome: Monitoring for and managing compartment syndrome, a serious condition caused by increased pressure in a muscle compartment.
  • Fat Embolism: Awareness of the rare risk of fat embolism, particularly in long bone insertion sites.

7. Pain Management

  • Local Anesthesia: Use of lidocaine or other local anesthetics to reduce pain during insertion, especially in conscious patients.
  • Post-Insertion Pain: Monitoring and managing any pain or discomfort associated with the IO line.

8. Training and Proficiency

  • Simulation Training: Regular training and practice using simulation models to maintain proficiency in IO insertion and management.
  • Certification: Ensuring certification and adherence to protocols established by the EMS service and medical oversight.

9. Legal and Ethical Considerations

  • Scope of Practice: Adhering to the legal scope of practice for their certification level and local regulations.
  • Informed Consent: Whenever possible, obtaining informed consent from the patient or their guardian before IO insertion.
  • Documentation: Accurate documentation of the indication, insertion site, device used, medications administered, and any complications encountered.


Effective IO medication administration requires EMS providers to combine detailed anatomical knowledge, practical skills, and a strong understanding of the indications, techniques, and potential complications. 

Continuous training and adherence to protocols are essential to ensure the safety and efficacy of this critical intervention. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Philbeck, T. E (2010) Pain Management with the use of IO. Journal of Emergency Medical Services. Accessed June 10, 2024

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