The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Wednesday, February 1, 2017

One Squeeze for Intraosseous Access

What happens in Vegas … saves lives. You thought we were going to say "stays in Vegas," right? But this is one new invention that should travel far and wide. Taking in all the wonder that is the American College of Emergency Physicians Scientific Assembly, we found many new products that piqued our interest, but we kept coming back to the PerSys New Intraosseous (NIO). Fluid replacement and stabilization during a code means everything. The time it takes to achieve patient resuscitation takes not only skills but also the appropriate tools.

Overwhelming evidence shows how useful intraosseous (IO) devices are to intravenous access. EPs should use IO insertion when peripheral or central lines cannot be obtained. The NIO is a single-motion instrument used to obtain IO access on the fly. This device has made headway in the battlefield and among EMS providers.

The NIO is used to obtain access on adult and pediatric patients and has three needle sizes. A study by the New York Institute of Technology (NYIT) College of Osteopathic Medicine found a 98 percent success rate for first attempts at insertion in the proximal tibia and 91 percent in the humeral head. Additional studies by NYIT performed found zero occurrences of microfractures and an average procedure time of 18.3 seconds. The NIO is FDA-approved, Health Canada-certified, and has received a CE Marking.


The thing we liked best about the NIO was that it was light and easy to use. Many of our ICU nurses carry the EZ-IO in fanny packs alongside their drugs. The drill is not that heavy, but it is still another thing someone has to carry around and clean. The NIO can be used once and thrown away. No drill or extra step is needed.

You simply place the NIO on one of the accepted sites, which include the proximal tibia, humeral head, and distal tibia. Then you turn the handle and the needle "pops" into place. As Dr. Roberts said, "It's easy, even for an old guy." Watch him in this step-by-step video.​

Contraindications of use include:

  • Skin infections at the insertion site
  • Bone disease
  • Bone fracture
  • Deformation of insertion site
  • Previous IO insertion attempts at the site
  • Previous orthopedic procedures at the insertion site
  • Tumor

We are curious about your favorite "new procedure toy" for the upcoming year. Let us know so we can learn more about it.

Disclaimer: No financial or material incentives were provided for this review. We just liked it.​