Nothing frustrates me more than not being able to obtain intravenous access in hemodynamically unstable patients, especially because I give a talk on “Troubleshooting the Difficult Vascular Access Patient.”

What would you do in this trauma case?

30 y/o man with multiple gun shot wounds in his right chest and arm. In PEA arrest. No IV access obtainable peripherally or centrally. IV access slowly being established via a saphenous cutdown. You know he’s bleeding internally and needs aggressive fluid resuscitation, blood transfusions, and operative repair.

Intraosseous needles

Adult intraosseous needles are coming more into favor in the United States, although they have been part of standard practice in the military and Europe. Various commercial devices exist. The one we have at SF General is the EZ IO Needle. (I have no financial ties with the company.) Needle placement is surprisingly easy and takes less than 10 seconds, especially if you channel your inner Home Depot self in using the power drill.

In the video below, 3 brave (a.k.a. crazy) volunteers get an IO drilled into their proximal tibia. Apparently, the insertion is only mildly painful and the infusion of fluids is actually the more painful part of the procedure. You might consider priming the IV tubing with 1% lidocaine to minimize pain in awake patients.

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD