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Intraosseous Rapid Sequence Intubation


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
  • AJ

    Is it superior to IM?

    • Christopher

      A 1989 animal study found IO to be equivalent to IV and superior to IM (PMID: 2602189). A 2001 human subjects study looked at IM rapacuronium for pedi RSI and was not favorable either (PMID: 11135715).

      Ron Walls had this to say regarding IM RSI, “The message is simple and consistent: When drugs are required to facilitate intubation, establish a line before intubating. Period.”

      • Salim R. Rezaie

        Hello Chris,

        TY for the links. I would also argue, that after the RSI is done, how does one plan to maintain sedation? Its hard to keep dosing IM, but you can run drips through the IO. IO is is fast and easy, with minimal contraindications or ill effects.

        I have had a couple of patients myself, that IV access was not possible, so IO was placed and we did RSI through the IO and it was smooth with no complications.

        I admit the evidence is not robust for using IO’s in RSI, but I don’t really see any literature 100% against this either.

        My take on all this is no evidence against use, current best evidence, although not robust, tells us that this is most likely ok for use in these complicated patients.

        Thank you for your comments.


  • Patrick DiCosimo

    Despite the limited literature, are there any limitations/preferences for the RSI drugs used IO vs IV?

    • Salim R. Rezaie

      Hello Patrick,
      I would use the same medications, that you would use IV. No evidence that pharmacokinetics are any different with either route. The only thing I would say, is that if you get a tibial IO, a IJ CVC anatomically would be closer to the central circulation. No evidence for this, but some advocate for slightly higher doses of RSI meds due to the distance that has to be traversed which means slightly longer time to effect.


  • Ed Barnard

    Thank you for presenting my research. The dose equivalence between IV and IO drug administration interests me. Some people consider IO access to be somewhere between peripheral IV and central venous access. However, at some point the drug will exit the bone and be carried to the heart via the venous system so it would make sense that in terms of pharmacokinetics it is closest to peripheral IV access.

    Confusingly in my study the physician-led prehospital team used relatively LOW doses of induction (ketamine), and relatively HIGH doses of paralytic (suxamethonium > rocuronium). This is explained in the discussion but in essence the profound hypovolaemia meant the patients only required a low dose of ketamine (and a higher dose may have been catastrophic), however they are given a higher dose of suxamethonium (median dose 200mg) in a ‘non-research base proven’ attempt at optimising intubating conditions. All the sux research examines low doses (0.6mg/kg-1.0mg/kg) in normovolemic, day-surgery patients. The intubation success of this team is very high and almost certainly multi-factorial, but maybe the high-dose paralytic plays a part?!

    • Salim R. Rezaie

      Thank you for your comments and explanation of the dosages used. Several of us were having a discussion about this the other day….whether higher dosages would be required or not as anatomically, IO more closely mimics peripheral IV and not central venous access.

      This was a great study, and the only one that I am aware that finished to completion looking at the use of RSI via the IO route. I myself have used this in a few cases where IV access was not possible and worked like a charm. Always nice to have evidence to support what we do in clinical practice. Thank you again.


  • Anna

    One end of standard wall suction tubing is connected via the included adapter to the NPA
    what is it? something we need to buy? I do not think we have it in our er