EZ IO Insertion

To see a video on “How to use an EZ IO device” click here.

Indications in the ED

  • When you fail to get intravenous access in a life threatening or resuscitation scenario.
  • In any acute situation when IV access is difficult or likely to lead to delay in management. (This decision should be taken in consultation with a senior medical officer).

Contraindications to a particular insertion site

  • Prosthesis or previous orthopaedic procedures near the insertion site - if the patient has a surgical scar over the insertion site - DO NOT USE IT!
  • Trauma/fracture in the insertion site.
  • Inability to locate the bony landmarks at the insertion site.
  • Infection at the insertion site.
  • IO insertion at the site in the last 48 hours.

Insertion sites

Image source: www.vidacare.com

Proximal Humerus

  • Highest flow rate - up to 5L/hr.
  • Least painful site.
  • To find the insertion site, place the patient’s arm in the adducted, pronated position with their hand lying over their umbilicus.
  • Run your thumb up the anterior humeral shaft until you feel the greater tubercle at the surgical neck. Approximately 1cm superior to this is the insertion site – the bony prominence of the greater tubercle.
  • Insert the needle at 45 degree off the anterior plane, and in a slightly downward angle.
  • At the humeral site in the adults (not in paediatrics) – you will need to insert the needle further than the other sites and the hub will be flush against the skin.
  • The 45mm (largest) needle is recommended in the humeral site in adults above 40kg.

Proximal Tibia

  • Flow rate up to 3300mL/hr.
  • To find the insertion site, measure approximately 2cm below the inferior aspect of the patella and then move medially to the flat aspect of the tibia.
  • The marker in the image are on the tibial tuberosity.

Distal Tibia

  • The insertion site is 2cm proximal to the most prominent aspect of the medial malleolus.

Needle choice

There are three needles to choose from:

  • 15mm: 3-39kg
  • 25mm: >40kg
  • 45mm: >40kg

Steps to Insert an EZ IO

  1. Select site, clean with antiseptic wipe.
  2. Choose appropriate needle based on patient weight and amount of soft tissue present at site.
  3. Prime the connector with normal saline.
  4. Attach needle set to the driver – allow magnet to connect between hub and driver.
  5. Remove safety cap.
  6. Stabilise the limb with your non dominant hand.
  7. Push needle through the skin until the tip of the needle rests on the bone – do not use the drill to push to needle through the skin.
  8. **Important to check that you can still see at least 1 black line on the needle before you enter bone – if you cannot, the needle is too short**.
  9. Squeeze the trigger – apply gentle steady pressure to insert the needle into the bone – hold the trigger “on” until you feel a loss of resistance.
  10. As you soon as you feel a loss of resistance stop drilling by removing your finger from the trigger – STOP WHEN YOU POP.
  11. Remove the drill from the needle set.
  12. Remove the stylet, leaving the cannula seated in the bone.

After insertion check

  • Firmly seated needle.
  • Aspirate a flash of blood.
  • No leaking around site.
  • Secure using EZ-Stabiliser.
  • Connect EZ–Connector.

If patient is alert you will need to give lignocaine before you flush the IO. See below.

Give lignocaine 2% at 0.5mg/kg

2% = 20mg/mL


Note – all ports need to flushed with 10mL normal saline before being connected to an infusion


Further ways to tell if you are in the bone

Further References and Resources

Patient Factsheet


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