Andy Little on the “No Ego IO”

In cardiac arrest, delayed vascular access delays reversible-cause treatment. For the difficult IV access patient, intraosseous access is the fastest reliable rescue line, while endotracheal drug delivery is too limited for problems like suspected hyperkalemia.

No Ego IO in Cardiac Arrest

• One attempt one minute: For arrest resuscitation, the rule is one nursing attempt and one minute for an 18-gauge AC-or-higher line; if that fails, move straight to IO rather than losing more time.
• Tibial plateau first choice: The proximal tibia is a practical first IO site in the crashing patient, giving immediate resuscitative access for meds and fluids while more definitive access waits. We walk through that bedside decision in the episode.
• Hyperkalemia access urgency: Suspected renal failure with possible hyperkalemia raises the stakes because calcium, bicarbonate, and other key therapies need vascular access now, not after repeated IV attempts.
• ET tube drug limits: Endotracheal drug delivery is a poor fallback here; the classic NAVEL options do not include the medications you actually need for suspected hyperkalemic arrest.
• IO reliability and capacity: IOs are reliable enough for most resuscitation drugs and can handle roughly 5 to 7 liters of fluid over 24 hours, making them a true bridge rather than a token line.

Access Strategy for Awake DIVA Patients

• Different algorithm when awake: Awake difficult-access patients need a different plan, with ultrasound-guided peripheral access, an Easy IJ, or a wire-friendly basilic approach often beating a reflex IO.
• Easy IJ bailout: A single-lumen 18-gauge right internal jugular line can function as a fast large-bore rescue option and may be exchanged over a guidewire if you later need central access.
• IO pain and cooperation: Avoid IO in a fully awake, aware patient when possible because periosteal infusion hurts and the visible drill-in-leg setup often creates immediate compliance problems.
• Analgesia through the IO: If an awake but altered patient truly needs an IO, local anesthetic to the periosteum plus lidocaine through the line can substantially reduce infusion pain.
• Who is a DIVA: ESRD, IV drug use, cancer, immunologic disease, sepsis, hypotension, cardiac arrest, and children in extremis are all high-risk patterns that should lower your threshold for early backup access.

References:

1. Hsieh YL, et al. Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies. Scand J Trauma Resusc Emerg Med. 2021;29(1):44. Published 2021 Mar 8. PMID: 33685486.
2. Feinstein BA, et al. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2017;117:91-96. PMID: 28629995.
3. Granfeldt A, et al. Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review. Resuscitation. 2020;149:150-157. PMID: 32142750.