IO-specific cautions

Time-limited draft: OCEMS circulated an April 2026 PR-115 redline with phased implementation beginning October 1, 2026 and final implementation April 1, 2027. This guide summarizes the version still listed on the current OCEMS procedure index as of September 16, 2026 and must be re-reviewed before that rollout.
Adenosine is not effective when administered through an IO site under PR-115.
Watch for infiltration, occlusion or poor flow, infection or sepsis, fat or bone embolus, and stress fracture.
If removal is required, follow the complete PR-115 removal procedure and apply a sterile dressing.

When IO access is indicated

Use IO access when normal saline or emergency life-saving medication is required for adult or pediatric cardiopulmonary arrest, respiratory arrest, or trauma-related arrest.
It is also indicated for life-threatening unstable vital signs under OCEMS Policy 310.30, or for an unconscious diabetic with blood glucose below 60 who does not respond to IM glucagon.

Do not use an extremity with a fracture, an insertion site with obvious skin or other infection, or an extremity that had an orthopedic procedure within the previous 6 weeks.
Do not use a site where excessive soft tissue prevents identification of the anatomic landmarks. Do not attempt insertion more than once at either tibia.

Prime extension tubing with fluid, choose the age-appropriate IO needle, and identify the proximal tibial insertion site using the landmarks in PR-115.
Use sterile gloves and prepare the site with alcohol or chlorhexidine. Stabilize the extremity and insert the device according to the manufacturer’s directions.
Remove the stylet into a sharps container. Connect tubing and normal saline; confirm the device is firmly seated and stable and look for blood at the hub or the ability to aspirate blood.

For a conscious adult/adolescent, slowly give preservative-free lidocaine 2% 20 mg through the IO over 1 minute; it may be repeated once for a total of 40 mg.
For a conscious child age 14 or younger, slowly give preservative-free lidocaine 2% 0.5 mg/kg through the IO over 1 minute, maximum 20 mg; do not repeat.
Flush before fluid or medication: adult/adolescent 10 mL normal saline; child age 14 or younger 5 mL. Repeat syringe flushes as needed, and pressurize the infusion bag if flow requires it.

Secure the catheter and tubing against dislodgement. Monitor flow and device stability and watch the extremity for extravasation.
Document every attempt, the insertion site, and placement time. Notify receiving staff of IO use and site even when an attempt was unsuccessful.