REBEL Core Cast 140.0: The Power and Limitations of Intraosseous Lines in Emergency Medicine

Sep 1, 2025

Discover the life-saving benefits of intraosseous lines in emergency medicine, especially during cardiac arrest. Fast placement and reliable access can deliver critical medications. Learn about the optimal locations for inserting these lines, and the differences in flow rates across various sites. Also discussed are key limitations, like potential dislodgement and the unreliability of lab results drawn from these lines. Not just for trauma, IO lines are vital in medical emergencies and challenging IV situations, particularly in pediatric patients.

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ANECDOTE

First IO Memory In A Crashing Child

Anand Swaminathan recalls his first IO placement as a third-year resident on a crashing child.
He fell in love with the device because it provided immediate access and allowed rapid resuscitation.

ADVICE

Use IO First In Cardiac Arrest

Do choose IO first in cardiac arrest and other crashing patients because placement is faster than IV or central access.
Give resuscitation drugs and blood through the IO without delaying for central lines.

ADVICE

One, Two, Then IO For Sick Kids

Try IO early in sick pediatric patients and limit IV attempts to two before switching to IO.
Use IO to avoid long delays chasing difficult peripheral access on unstable kids.

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📌 Key Points

💉 IO Lines Are Life-Saving in Extremis: IO access is fast, reliable, and can deliver nearly any resuscitative medication or fluid during cardiac arrest or hemorrhagic shock.
🧭 Location Matters for Flow. Sternal IO: 💨 Fastest (up to 500cc/5 min). Humerus IO: ⚡ Faster than tibia (300cc/5 min). Tibial IO: 🐢 Slower (200cc/5 min) but easier to place during CPR
⚠️ Watch for Contraindications: Avoid IO placement in bones with fractures, prior IO attempts, or compromised circulation proximal to the site.
🩸 Labs From IO = ❌: Labs drawn from IO lines are generally unreliable. Once stabilized, obtain bloodwork through IV access.
🎯 Stabilize or Lose It: IO dislodgement is common—always use a stabilizer or secure with gauze and tape if none is provided.
🧠 Don’t Forget Non-Trauma Uses: IO isn’t just for trauma—think about it in medical arrests, shocked pediatric patients, and patients with difficult IV access.

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⏰ Highlights

00:00 Introduction to the Podcast
00:07 First Encounter with Intraosseous Lines
01:09 Advantages of Intraosseous Lines
02:42 Intraosseous Lines in Pediatric Patients
03:34 Optimal Locations for Intraosseous Lines
06:17 Limitations and Considerations
07:34 Conclusion and Final Thoughts

📝 Introduction

Welcome to the Rebel Core Content blog, your go-to source for core medical concepts applicable to practitioners anywhere, anytime. Today, we delve into the world of Intraosseous (IO) lines—a crucial tool in emergency medicine. Swami shares insights into the effectiveness and limitations of IO usage in diverse clinical scenarios.

🧠 Background

The sicker the patient, the more likely an IO line is the right choice. In emergencies such as cardiac arrest or hemorrhagic shock, the speed and reliability of IO access outshine traditional intravenous (IV) or central line placements. There’s virtually no resuscitation medication or blood product that cannot be administered through an IO, making it indispensable in life-threatening situations.

🧭 Location

While proximal humerus site portents faster infusion rates than proximal tibia site, the main limitation of the proximal humerus site is that the arm must be held in internal rotation to avoid dislodgement of the IO
Proximal tibia may be easier to landmark than proximal humerus
Other sites include distal tibia, distal femur and sternum but are uncommonly employed in EDs

🚰 Flow Rates

Proximal Humerus IO
- ~300cc over 5 minutes
- Faster than tibia
- May be harder to access in some trauma or positioning scenarios
Tibial IO
- ~200cc over 5 minutes
- Slower flow compared to humerus
- Easier to access, especially during CPR or transport
Sternal IO
- Up to 500cc over 5 minutes
- Highest flow rate
- Best for rapid volume resuscitation
- Risk of dislodgement or interfering with CPR compressions

⚠️ Limitations

Placing an IO in a bone with a proximal fracture, a previous IO placement attempt or any circulatory compromise proximal to the site is contraindicated
Blood work drawn from an IO are generally not accurate, so once the patient has been resuscitated with the IO, intravenous blood draws are recommended
Dislodgement is common; it is best to use the stabilizer that comes with the IO kit; if the kit does not have a stabilizer, stack lots of gauze on both sides of the IO needle and tape it down

🚨 Clinical Bottom Line

Intraosseous lines are a powerful tool, particularly in acute resuscitation scenarios involving cardiac arrest or severe trauma. While they offer quick and effective access, Clinicians must remain vigilant about their limitations and be prepared to switch to more stable options as patients stabilize.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Associate Editor

Anand Swaminathan

MD, MPH

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The post REBEL Core Cast 140.0: The Power and Limitations of Intraosseous Lines in Emergency Medicine appeared first on REBEL EM - Emergency Medicine Blog.

REBEL Core Cast 140.0: The Power and Limitations of Intraosseous Lines in Emergency Medicine

First IO Memory In A Crashing Child

Use IO First In Cardiac Arrest

One, Two, Then IO For Sick Kids