Download Myth #2: The proximal tibia is the best site for IO vascular access

Myth #2: The proximal tibia is the best site for IO vascular access.
Reality: Any IO site that can be quickly, safely, and effectively accessed may be best for any
given patient but for many adult patients, the proximal humerus may be the best site for IO
vascular access. This site results in less infusion pain for conscious patients, greater flow rates,
better accessibility, and faster delivery of medication to the central circulation.
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Several studies support the proximal humerus as a successful or even superior IO route
for flow rates, drug delivery, and management of infusion pain (1-4). One of the first
descriptions of humeral intraosseous IO use, published in Journal of Trauma, compared
various vascular access methods including proximal humerus IO, peripheral venous
access and central venous access routes. The study concluded that proximal humerus IO
was significantly faster than the other two routes in terms of time to vascular access (5).
o Drug Delivery: A preclinical study in 2006 using epinephrine demonstrated that
humeral IO access generated higher mean arterial pressures than central venous
access. The authors concluded IO humeral delivery of epinephrine during cardiac
arrest is as effective as intravenous infusion (6). A 2007 study in swine compared
the proximal humerus and sternal routes during CPR, and concluded the humerus
route is an effective alternative to IO sternal delivery during CPR (7).
o Flow Rates: Pre-clinical, volunteer, and clinical studies have evaluated flow rates
using various sites and pressure methods. Generally, evidence to date supports the
proximal humerus as the site of choice when maximum flow rates are desired (3,
7-9).
o Pain Management: A 2010 article reported the combined results of two studies
examining pain management with IO vascular access(3). These volunteer studies
using the humerus and tibia demonstrated that less pressure was required to infuse
through the humerus than the tibia route, and demonstrated a direct correlation
between infusion pressure and pain level (increased pain with greater infusion
pressures).
o Faster Time to Central Circulation: Anatomically, functions as an internal
jugular or subclavian central line.
o Click on link to see flow study.
With proper training and implementation, the proximal humeral first time success rates
are comparable to tibial and, in fact, exceed peripheral IV first attempt success rates. This
site is easily identifiable with proper landmark training; and stable when using correct
needle length (45 mm for most adults), and IO set and patient arm are secured well.
Watch this training video to learn how.
(1) Kovar J, Gillum L. Alternate route: the humerus bone—a viable option for IO access. JEMS 2010;35(8):
52-9.
(2) Wampler D, Schwartz D, Shumaker J, et al. Paramedics successfully perform humeral EZ-IO
intraosseous access in adult out-of-hospital cardiac arrest patients. Am J Emerg Med 2010;56(3):S88. VS
doi.org/10.1016/j.ajem.2011.07.010.
(3) Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good; easing IO pain and pressure. JEMS
2010;35(9):58-69.
(4) Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency
venous access. J Trauma 2009;67(3):606-11.
(5) Hoskins SL, Kramer GC, Stephens CT, Zachariah BS. Efficacy of epinephrine delivery via the
intraosseous humeral head route during CPR. Circulation 2006;114:II_1204.
(6) Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparison of intraosseous proximal humerus and
sternal routes for drug delivery during CPR. Circulation 2007;116:II_933.
(7) Warren DW, Kissoon N, Sommerauer JF, Rieder MJ. Comparison of fluid infusion rates among
peripheral intravenous and humerus, femur, malleolus, and tibial intraosseous sites in normovolemic and
hypovolemic piglets. Ann Emerg Med 1993;22(2):183-6.
(8) Lairet J, Bebarta V, Lairet K et al. A comparison of proximal tibia, proximal humerus, and distal femur
infusion rates under high pressure (>300 mmHg) using the EZ-IO intraosseous device on an adult swine
(sus scrofa) model. Prehosp Emerg Care 2011;15(1):117.
(9) Lairet JR, Bebarta V, Lairet K et al. Intraosseous pressure infusion comparison using a rapid infusion
device and a pressure bag in a swine model. Ann EmergMed 2010;56(3):S26.