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[ Home ](https://mdster.com) 2. [ Blog ](https://mdster.com/blog) 3. [ Medical Education ](https://mdster.com/blog?category=medical-education) 4. Intraosseous Access Technique and Confirmation: An ED Guide [ Medical Education ](https://mdster.com/blog?category=medical-education) Intraosseous Access Technique and Confirmation: An ED Guide ============================================================= Choose the right needle, prove functional placement, and keep pressure infusion safe. [ MDster Editorial Team ](https://mdster.com/about) · Sep 22, 2026 · 7 min read · 414 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) \| [Corrections Policy](https://mdster.com/corrections) [ Board Review ](https://mdster.com/blog?tag=board-review) [ Emergency Medicine ](https://mdster.com/blog?tag=emergency-medicine) [ Procedural Skills ](https://mdster.com/blog?tag=procedural-skills) [ Intraosseous Access ](https://mdster.com/blog?tag=intraosseous-access) ![Intraosseous Access Technique and Confirmation: An ED Guide](https://mdster.com/storage/blog/images/intraosseous-access-technique-and-confirmation-an-ed-guide.jpg) Share this article Share this post On this page 1. [ Choose the Site and Needle Together ](#choose-the-site-and-needle-together) 2. [ Landmark deliberately ](#landmark-deliberately) 3. [ Select length by tissue depth ](#select-length-by-tissue-depth) 4. [ Insert With Control, Not Force ](#insert-with-control-not-force) 5. [ Confirm With Aspiration and an Observed Flush ](#confirm-with-aspiration-and-an-observed-flush) 6. [ Make confirmation a bundle ](#make-confirmation-a-bundle) 7. [ Address infusion pain before flushing ](#address-infusion-pain-before-flushing) 8. [ Secure Before Applying Pressure ](#secure-before-applying-pressure) 9. [ Pressure must follow confirmation ](#pressure-must-follow-confirmation) 10. [ Key Takeaways ](#key-takeaways) 11. [ Frequently Asked Questions ](#blog-faqs) 12. [ References ](#references-heading) On this page 1. [ Choose the Site and Needle Together ](#choose-the-site-and-needle-together) 2. [ Landmark deliberately ](#landmark-deliberately) 3. [ Select length by tissue depth ](#select-length-by-tissue-depth) 4. [ Insert With Control, Not Force ](#insert-with-control-not-force) 5. [ Confirm With Aspiration and an Observed Flush ](#confirm-with-aspiration-and-an-observed-flush) 6. [ Make confirmation a bundle ](#make-confirmation-a-bundle) 7. [ Address infusion pain before flushing ](#address-infusion-pain-before-flushing) 8. [ Secure Before Applying Pressure ](#secure-before-applying-pressure) 9. [ Pressure must follow confirmation ](#pressure-must-follow-confirmation) 10. [ Key Takeaways ](#key-takeaways) 11. [ Frequently Asked Questions ](#blog-faqs) 12. [ References ](#references-heading) The tibial IO feels solid, but the saline flush produces swelling. In this resuscitation scenario, the correct move is to stop—not increase pressure. Catheter stability alone does not establish usable vascular access. [\[1\]](#cite-1 "Reference [1]") Think in three steps: **reach marrow, demonstrate functional placement, then protect that placement**. This September 2026 review focuses on powered IO technique; follow the instructions for your specific device rather than transferring needle lengths or insertion angles between systems. Choose the Site and Needle Together ----------------------------------- Exclude a fractured target bone, local infection, significant orthopedic hardware or surgery at the site, and inadequate landmarks. For EZ-IO, an attempt in the same bone within the preceding 48 hours also excludes that bone. [\[2\]](#cite-2 "Reference [2]") ### Landmark deliberately Use palpable anatomy—not an estimated location beneath clothing. The following adult landmarks describe EZ-IO technique: - At the proximal tibia, extend the leg and identify the flat anteromedial surface, approximately 2 cm medial to the tibial tuberosity. Enter perpendicular to the bone. [\[3\]](#cite-3 "Reference [3]") - At the proximal humerus, adduct and internally rotate the arm, with the hand over the abdomen. Palpate the greater tubercle approximately 1–2 cm above the surgical neck; direct the needle posteromedially, approximately 45 degrees to the anterior plane. [\[4\]](#cite-4 "Reference [4]") Do not copy adult distances onto infants. Pediatric tibial landmarks vary with size; identify the flat anteromedial surface below the tuberosity and avoid the physis. [\[5\]](#cite-5 "Reference [5]") ### Select length by tissue depth EZ-IO needles are 15-gauge and available in 15-, 25-, and 45-mm lengths. Advance through skin to contact bone before activating the driver: **at least one black depth mark—5 mm—must remain visible above the skin**. If it disappears, choose a longer needle or another site. [\[2\]](#cite-2 "Reference [2]") Weight and color coding are starting points, not substitutes for that depth check. The 45-mm needle is commonly appropriate for adult humeral placement, where overlying tissue can consume much of a shorter needle’s length. [\[6\]](#cite-6 "Reference [6]") Insert With Control, Not Force ------------------------------ Prepare the antiseptic-cleaned site, let it dry, and stabilize the limb. Have a primed extension set, saline syringe, and stabilizing dressing ready before drilling. [\[1\]](#cite-1 "Reference [1]") 1. Contact bone and verify sufficient exposed needle length. 2. Activate the driver with gentle, steady pressure; let the device advance. 3. Recognize the loss of resistance as marrow is entered. Avoid unnecessary advancement, especially in small children, where through-and-through penetration is a concern. 4. Stabilize the hub while removing the driver and stylet. [\[5\]](#cite-5 "Reference [5]") A tactile “give” supports placement, but it does not complete confirmation. Next, assess catheter stability and functional flow. [\[1\]](#cite-1 "Reference [1]") Confirm With Aspiration and an Observed Flush --------------------------------------------- Attempt aspiration of blood or marrow after removing the stylet. A positive aspirate supports placement, but **failure to aspirate does not establish failure**. [\[5\]](#cite-5 "Reference [5]") ### Make confirmation a bundle Use several findings together rather than treating any single sign as definitive: - The catheter remains stable in bone. - Blood or marrow may be aspirated. - Saline passes without leakage or expanding soft-tissue swelling. [\[1\]](#cite-1 "Reference [1]") For EZ-IO, flush with 0.9% saline: 5–10 mL in adults or 2–5 mL in infants and children, following local protocol. The initial flush helps establish flow through the marrow space; do not skip it and then interpret poor gravity flow as malposition. [\[7\]](#cite-7 "Reference [7]") Watch and palpate the surrounding tissue while flushing. Stop if swelling develops or resistance prevents flushing; do not force fluid through a questionable catheter. [\[1\]](#cite-1 "Reference [1]") > Clinical Pearl: A dry aspiration is inconclusive. A stable catheter that flushes without swelling may still be correctly positioned. [\[5\]](#cite-5 "Reference [5]") ### Address infusion pain before flushing In a patient responsive to pain, consider slowly administered preservative-free, epinephrine-free lidocaine through the IO before the saline flush, using institutional dosing and contraindication checks. Add systemic analgesia when necessary; infusion pain deserves treatment even when insertion was tolerated. [\[7\]](#cite-7 "Reference [7]") Routine radiography is unnecessary after clinically successful placement. Suspected fracture or unresolved concern requires reassessment rather than assuming a normal-looking hub proves correct position. [\[5\]](#cite-5 "Reference [5]") Secure Before Applying Pressure ------------------------------- Apply the device-compatible stabilizing dressing and firmly connect the primed extension tubing. Support the tubing so handling syringes or moving the patient does not transmit torque to the catheter. For humeral IOs, maintain the arm adducted and secured against the torso. [\[2\]](#cite-2 "Reference [2]") Gravity alone often provides inadequate IO flow. After confirmation and flushing, use a pressure bag, infusion pump, or controlled syringe delivery appropriate to the prescribed therapy. [\[7\]](#cite-7 "Reference [7]") ### Pressure must follow confirmation Pressure overcomes resistance within the IO system; it cannot correct extravasation. If delivery slows, inspect the limb and catheter, check connections and clamps, and reassess patency before escalating pressure. [\[8\]](#cite-8 "Reference [8]") Keep the site visible during infusion and reassess after transfers. New swelling, increasing firmness, altered sensation, or worsening limb pain should trigger immediate cessation and evaluation for extravasation or compartment syndrome. [\[1\]](#cite-1 "Reference [1]") Key Takeaways ------------- - Match needle length to tissue depth, not age labels alone. [\[2\]](#cite-2 "Reference [2]") - Do not reject an otherwise functional IO solely because aspiration is dry. [\[5\]](#cite-5 "Reference [5]") - Confirm before pressurizing; stop for swelling. [\[1\]](#cite-1 "Reference [1]") - Stabilize the catheter, tubing, and limb—not just the hub. [\[2\]](#cite-2 "Reference [2]") The endpoint is not “needle inserted.” It is confirmed, secured access under ongoing observation. Replace the IO with suitable venous access as soon as feasible. [\[5\]](#cite-5 "Reference [5]") Frequently Asked Questions ---------------------------- ### Does failure to aspirate marrow mean the IO must be replaced? No. Assess stability and an observed saline flush without extravasation; aspiration can be unsuccessful despite correct placement. [\[5\]](#cite-5 "Reference [5]") ### What should I do if the EZ-IO depth mark disappears before drilling? Choose a longer needle or another site. At bone contact, at least 5 mm must remain visible above skin. [\[2\]](#cite-2 "Reference [2]") ### Can an IO be correctly positioned but flow poorly by gravity? Yes. Initial flushing and pressure-assisted delivery are commonly needed. Reassess patency and exclude extravasation before increasing pressure. [\[7\]](#cite-7 "Reference [7]") References (8) ------------------ 1. 1. [ Perth Children’s Hospital. Emergency Department Guidelines: Intraosseous access. ](https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Intraosseous-access) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ www.teleflexvascular.com/files/ifu/8089A.pdf ](https://www.teleflexvascular.com/files/ifu/8089A.pdf) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ www.teleflex.com/global/clinical-resources/documents/MCI-2019-0401\_VA\_EZIO\_Proximal\_Tibia\_Site\_Identification\_%26\_Insertion\_Technique\_%28Adult%29\_LR.pdf ](https://www.teleflex.com/global/clinical-resources/documents/MCI-2019-0401_VA_EZIO_Proximal_Tibia_Site_Identification_%26_Insertion_Technique_%28Adult%29_LR.pdf) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ www.teleflex.com/global/clinical-resources/documents/MCI-2019-0400\_Proximal\_Humerus\_Site\_Identification\_%26\_Insertion\_Technique\_%28Adult%29\_LR.pdf ](https://www.teleflex.com/global/clinical-resources/documents/MCI-2019-0400_Proximal_Humerus_Site_Identification_%26_Insertion_Technique_%28Adult%29_LR.pdf) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Intraosseous access. Updated December 2024. ](https://www.rch.org.au/clinicalguide/guideline_index/intraosseous_access/) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ www.teleflex.com/emea/en/product-areas/emergency-medicine/intraosseous-access/arrow-ez-io-system/literature/MCI-2018-0198\_VA\_EZ-IO-FAQ\_Science\_and\_Fundamentals-EN\_LR.pdf ](https://www.teleflex.com/emea/en/product-areas/emergency-medicine/intraosseous-access/arrow-ez-io-system/literature/MCI-2018-0198_VA_EZ-IO-FAQ_Science_and_Fundamentals-EN_LR.pdf) [↩](#cite-ref-6-1 "Back to text") 7. 7. [ www.teleflex.com/usa/en/product-areas/emergency-medicine/intraosseous-access/arrow-ez-io-system/literature/VA\_IO\_Arrow-EZ-IO-Care-Maint.pdf ](https://www.teleflex.com/usa/en/product-areas/emergency-medicine/intraosseous-access/arrow-ez-io-system/literature/VA_IO_Arrow-EZ-IO-Care-Maint.pdf) [↩](#cite-ref-7-1 "Back to text") 8. 8. [ www.teleflex.com/global/clinical-resources/documents/EZ-IO\_Science\_Fundamentals\_MC-003266-Rev1-1.pdf ](https://www.teleflex.com/global/clinical-resources/documents/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf) [↩](#cite-ref-8-1 "Back to text") Next step Get faster at Emergency Medicine decision‑making -------------------------------------------------- - Rapid, exam‑style questions across core ED topics - High‑yield differentials and next‑step management - Target weak areas with smart review [ Start practicing ](https://mdster.com/user/dashboard) [ Explore Emergency Medicine ](https://mdster.com/speciality/emergency-medicine) [ View pricing ](https://mdster.com/pricing) [ Explore features ](https://mdster.com/features) No credit card required. Full access to all features\*. No commitment. Cancel anytime. \*AI SOE Examiner is limited to 10 cases monthly for Advanced & Bundle subscribers. 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