Intraosseous Rapid Sequence IntubationIntravenous (IV) rapid sequence intubation (RSI) is by most considered the gold standard practice for securing an airway in the critically ill. There are, however, scenarios where it may not be possible to get rapid IV access in a timely manner (i.e. severe cutaneous burns, hemorrhagic shock, IV drug users, and/or the morbidly obese). It has been reported that intraosseous (IO) drug administration has similar pharmacokinetics to IV administration, but there have only been a handful of cases reported using the IO route for RSI. In this post we will discuss intraosseous rapid sequence intubation and if it is a feasible practice.

What are the advantages of IO vs IV access [1]?

  • The infusion space of the medullary  cavity of long bones does not collapse in hypovolemia
  • IO needles are faster to insert vs IV catheters [2]
  • IO needles have a high insertion success rate vs IV catheters [3]
  • IO needle placement has a better skill retention than IV catheters [4]

 Have there been other studies looking at IO RSI?

  • Observational Study of Rapid Sequence Intubation (RSI) Drug Delivery Using Intraosseous (IO) and Intravenous (IV) Access: Terminated early due to poor enrollment [Clinicaltrials website]

What is the most current and best evidence for IO RSI [1]?

What they did: 

  • Prospective, observational study at a combat hospital in Afghanistan
  • 34 trauma patients underwent RSI with IO drug administration

Primary Outcome: Success rate of first-pass intubation with direct laryngoscopy


  • Patient median age: 24 years (Range 8 – 45 years)
  • Gender: All male
  • Most common RSI drugs used:
    • Induction medication: Ketamine (97.0%)
    • Paralytic medication: Suxamethonium (73.5%) and Rocuronium (26.5%)
  • Most frequently used IO sites: Humeral head (54.3%) > sternum (37.1%) > tibia (8.6%)
  • First-pass intubation success rate 97% (95% CI 91 – 100%)


  • Observational study with a small (34 patients), select population (i.e young males with trauma)
  • No comparison of IV vs IO for 1st pass intubation success rates

Conclusions: IO drug administration can be used successfully for trauma RSI

Take Home Message

IO administration of RSI drugs appears to be a feasible practice with similar 1st pass intubation success rates as the IV route when IV access is not rapidly accessible.



  1. Barnard EBG, Moy RJ, Kehoe AD, Bebarta VS, Smith JE. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014. PMID: 24963149.
  2. Hulse EJ, Thomas GOR. Vascular access on the 21st century military battlefield. J R Army Med Corps. 2010;156(4 Suppl 1):385-390. PMID: 21302661.
  3. Reades R, Studnek JR, Vandeventer S, Garrett J. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial. Ann Emerg Med. 2011;58(6):509-516. PMID: 21856044.
  4. Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med. 1993;22(7):1119-1124. PMID: 8517560.
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor Clinical Assistant Professor of EM and IM University of Texas Health Science Center at San Antonio Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews