Intraosseous Access
Intraosseous access, [right / left] [proximal tibia / distal tibia / proximal humerus]
[Cardiac arrest / Hemorrhagic shock / Decompensated shock] requiring emergent vascular access for medication and fluid administration [after [X] failed peripheral IV attempts / with peripheral access not feasible in the time available].
[The procedure was emergent, and consent was implied / Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives]. [The family was notified.]
[***, MD/DO]
[None / IO lidocaine: 40 mg of 2% preservative-free lidocaine for a conscious patient]
Correct marrow cavity position was confirmed by [aspiration of bone marrow and resistance-free flush / resistance-free flush without subcutaneous extravasation]. Medications and fluids were administered successfully through the IO.
[A time-out was completed confirming the patient, procedure, and site.] The [right / left] [proximal tibia / distal tibia / proximal humerus] was selected as the access site. [The knee was slightly flexed, the tibial tuberosity was palpated, and the insertion site was identified 2 cm medial and 2 cm distal to the tibial tuberosity on the flat anteromedial surface.] The site was [prepped with chlorhexidine / not prepped given the emergent circumstances].
A [15 / 25 / 45] mm IO needle was inserted perpendicular to the bone with [the EZ-IO powered driver / a manual rotary motion] until a loss of resistance was felt on entering the marrow cavity. The needle was stable and stood unsupported when released. The stylet was removed, and bone marrow was aspirated.
[For a conscious patient, 40 mg (2 mL) of 2% preservative-free lidocaine was infused slowly through the IO over 120 seconds.] The IO was flushed with [10] mL of normal saline without resistance or extravasation. The IO was connected to the infusion line with a Luer-lock extension set, and fluids and medications were administered.
The IO was secured, and the extremity was labeled prominently. [The IO was used until conventional vascular access was established [X] minutes later, and the needle was then removed. The insertion site showed no extravasation, compartment syndrome, or signs of infection.]
[15 / 25 / 45] mm [EZ-IO / manual] intraosseous needle, [right / left] [proximal tibia / distal tibia / proximal humerus], [secured and labeled / removed after conventional vascular access was established]
None
[Bone marrow aspirate sent for type and screen, chemistries, and blood gas because peripheral blood was not available / None]
None
The extremity will be monitored for extravasation and compartment syndrome. [The IO will be removed once peripheral or central venous access is established, within 24 hours of placement.]
Epic SmartPhrase Version
PROCEDURE: Intraosseous access, *** ***
INDICATION: *** requiring emergent vascular access. *** failed peripheral IV attempts.
CONSENT: [Emergent, consent implied / Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives].
PERFORMED BY: ***, MD/DO
ANESTHESIA: [None / IO lidocaine 40 mg for conscious patient]
FINDINGS: Marrow cavity position confirmed by *** without extravasation. Medications and fluids administered successfully.
PROCEDURE DETAILS:
[Time-out completed.] *** selected as IO site. Landmarks identified by palpation. Site prepped ***. *** mm IO needle inserted perpendicular to bone with ***. Loss of resistance on entering marrow cavity. Needle stable on release. Stylet removed, marrow aspirated. [IO lidocaine 40 mg infused over 120 seconds.] Flushed with 10 mL NS without resistance or extravasation. Connected to infusion line. Secured and labeled. [Used until *** access established *** minutes later, then removed. Site without extravasation.]
DEVICE PLACED: *** mm [EZ-IO / manual] IO needle, ***, [secured and labeled / removed]
EBL: None
SPECIMENS: ***
COMPLICATIONS: None
POST-PROCEDURE PLAN: Extremity monitored for extravasation and compartment syndrome. IO to be removed once conventional access established, within 24 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Humeral Head Approach
The humeral head approach was used given [leg injuries / bilateral lower extremity fractures / prior tibial IO attempts]. The patient's arm was adducted and internally rotated. The greater tubercle of the humerus was identified 2 cm above the surgical neck. A 25 mm EZ-IO needle was inserted at a 45-degree angle directed toward the elbow. Marrow aspiration and resistance-free flush confirmed correct position.
Pediatric IO (Manual Needle)
In the pediatric patient ([age] years, [weight] kg), IO access was established using a [Cook / Jamshidi] manual IO needle. The proximal tibia was accessed [1-2 cm medial and 1 cm distal to the tibial tuberosity] perpendicular to the bone on the flat anteromedial surface. A rotary motion was used to advance the needle. The stylet was removed and aspiration/flush confirmed correct positioning. Weight-based doses were calculated for all medications administered.
Charting Tips
- Document the number of failed IV attempts that justified IO placement. This establishes medical necessity. In adult cardiac arrest, peripheral IV access is attempted first, and IO access is used when IV attempts are unsuccessful or not feasible.
- Document confirmation of correct placement by aspiration of marrow AND resistance-free flush. A misplaced IO that extravasates into soft tissue can cause compartment syndrome, and explicit confirmation documentation is critical.
- IO access should be converted to conventional IV/central access as soon as clinically feasible. Document the time the IO was placed and the time it was removed. IO should not remain in place >24 hours due to osteomyelitis risk.
- Sternal IO (FAST1 device) is a specialized device for adult use only, requires dedicated training, and is absolutely contraindicated during active chest compressions. It is not interchangeable with EZ-IO technique. If used, document device type, rationale, and that CPR was not in progress at the time of insertion.
- IO lidocaine for a conscious patient: infuse 40 mg (2 mL of 2% preservative-free lidocaine) slowly over 120 seconds before the saline flush to reduce infusion pain. The pediatric dose is 0.5 mg/kg IO.
- Proximal humeral IO access generally achieves higher flow rates than tibial access. Bone marrow aspirate is reliable for type and screen and most chemistries but not for a CBC.
Documentation & Reimbursement Considerations
- Primary service: Report Intraosseous Access as the primary service when it is the definitive operation performed.
- Intraosseous catheter placement (1.17 wRVU, 0-day global) is a single service covering manual, drill-based (EZ-IO), and impact-based (FAST1) IO devices. Technique does not change the code.
- 0-day global: no bundled postoperative period.
- When performed as a standalone emergent procedure (e.g., by surgery, EM, or anesthesia before a case), IO placement is separately billable. Document the indication, site, device, and confirmation of placement.
- IO access is a temporary measure. When a central or peripheral IV is subsequently placed in the same encounter, only the definitive access code needs to be billed separately. IO and CVL in the same resuscitation are not typically both billed.