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What sites are approved for IO placement?

Question# 755

Can there be some clarification on humoral IO for both pediatrics and adults. My ACP colleagues in 2023 Fall CME are being told humoral is authorized for all ages but MedicASK answer from Nov 6, 2023 says proximal tibia is the only authorized site by RPPEO. ALS-PCS does not specify site. Companion Document says sites other than proximal tibia is based on RBHP approval. Thanks.


Advanced Care Paramedics may place intraosseous (IO) needles at approved sites, subject to them being trained and knowledgeable on IO cannulation of these sites, with due consideration to the warnings and contraindications, and having the appropriate IO insertion device.

The approved site for for all ages is the proximal tibia.

Additionally the proximal humerus is approved for patients greater than 18 years.

Additional to the contraindications described in the ALS PCS (fracture, crush injury, or prosthesis/replacement proximal to the cannulation site), placement of IO should be avoided in:

bones with a prior failed IO placement attempt;
extremities with vascular disruption;
access sites near burns or infection;
patients with osteogenesis imperfecta or osteopetrosis; or
patients with right to left congenital cardiac shunts.


Pasley, et al. 2015. Intraosseous infusion rates under high pressure: a cadaveric comparison of anatomic sites.
Petitpas, et al. 2016. Use of intra-osseous access in adults: a systematic review.
Perron, 2022. Intraosseous infusion. UpToDate.
Stimac, 2015. Resuscitation and the Humeral Intraosseous Line.

Intraosseous Access.


Medical Directive Category

Intravenous Access


01 December 2023

ALSPCS Version




Please reference the MOST RECENT ALS PCS for updates and changes to these directives.