Intraosseous Access Summary

Indications

  • IV access difficult/impossible
  • APLS: if venous access fails or takes >1 min
  • Recommended for cardiac arrest in children

Insertion Sites

  • Adults: Proximal humerus, proximal tibia, distal tibia
  • Pediatrics: Proximal tibia, distal femur

Contraindications

  • Trauma at target site
  • Infection at target site
  • Prosthesis at target site
  • Recent IO access in same limb
  • Landmarks not identifiable

Procedure

  • Device-specific training essential
  • Aspirate to confirm placement
  • Flush with saline to ensure patency
  • Use pressure for fluid administration

Complications

  • Extravasation
  • Needle dislodgement
  • Compartment syndrome
  • Bone fracture/chipping
  • Physeal plate injury (children)
  • Infection/osteomyelitis

Intraosseous Access

Comprehensive guide to intraosseous access for emergency vascular access

Introduction

If intravenous (IV) access is difficult or impossible, consider the intraosseous (IO) route. IO injection of drugs achieves adequate plasma concentrations in a time comparable with injection through a vein.

APLS Guidelines

APLS guidelines recommend that intraosseous access is indicated if other attempts at venous access fail or if they will take longer than 1 minute to carry out. IO is also the recommended technique for circulatory access in cardiac arrest in children.

Insertion Sites

Adult Sites

The three main insertion sites for IO access recommended for use in adults are:

  • Proximal humerus
  • Proximal tibia
  • Distal tibia

Pediatric Sites

APLS guidelines suggest that the following are the preferred sites in pediatric patients:

  • Proximal tibia
  • Distal femur

Site Landmarks

  • Humeral insertion: Lateral surface of the proximal humerus, at the most prominent aspect of the greater tubercle (about 1 cm above the surgical neck)
  • Proximal tibial insertion: Anterior surface of the proximal tibia, 2-3 cm below the tibial tuberosity
  • Distal tibial insertion: Anterior surface of the distal tibia, 3 cm above the most prominent aspect of the medial malleolus
  • Distal femur insertion: Anterolateral surface of the distal femur, 3 cm above the lateral condyle

Contraindications

Absolute Contraindications

  • Trauma at target site
  • Infection at target site
  • Prosthesis at target site
  • Recent IO access (previous 48 hours) in same limb (including failed access)
  • Failure to identify anatomical landmarks

Procedure

Training Requirement

Training in the specific device to be used in clinical practice is essential. Site of insertion, identification of landmarks and technique for insertion will differ depending on the device being used.

Step-by-Step Procedure

  1. Prepare equipment: Ensure all necessary equipment is ready including IO device, antiseptic solution, sterile gloves, and flush solution
  2. Position patient: Position the patient appropriately for the selected insertion site
  3. Identify landmarks: Palpate and identify the correct anatomical landmarks for the chosen site
  4. Clean site: Prepare the site with antiseptic solution using an aseptic technique
  5. Insert needle: Insert the IO needle using the appropriate technique for the specific device
  6. Confirm placement: Once inserted, confirm correct placement before delivery of drugs or infusion of fluids
    • Attempt to aspirate from the needle; presence of IO blood indicates correct placement
    • Absence of aspirate does not necessarily imply a failed attempt
  7. Flush the needle: Flush with 0.9% saline to ensure patency and observe for leakage or extravasation
    • This is best achieved using an extension set with 0.9% saline attached to the hub of the needle before use
  8. Secure device: Secure the IO needle according to manufacturer's instructions

Administration of Medications and Fluids

Medications

Once IO access has been confirmed, resuscitation drugs including adrenaline and amiodarone can be infused.

Fluids and Blood Products

Fluids and blood products can also be delivered but pressure will be needed to achieve reasonable flow rates using either a pressure bag or syringe.

Important Note

Follow the manufacturer's guide both for securing the needle and the maximum length of time it can be left in place.

Complications

Immediate Complications

  • Extravasation into soft tissues surrounding insertion site
  • Dislodgement of needle
  • Fracture or chipping of bone during insertion
  • Pain related to infusion of drugs/fluid

Serious Complications

  • Compartment syndrome (secondary to extravasation)
  • Physeal plate injury in children
  • Fat emboli

Late Complications

  • Local infection
  • Osteomyelitis

Comparison of IO Access Sites

Site Advantages Disadvantages Best For
Proximal Humerus Easy access, high flow rates, less painful Risk of radial nerve injury, harder to secure Adults, emergency situations
Proximal Tibia Easy to identify landmarks, stable for securing Slower flow rates, more painful Children, stable patients
Distal Tibia Easy access, good for securing Smaller bone, lower flow rates Adults and children when other sites unavailable
Distal Femur Good flow rates, easy access in infants Risk of growth plate injury in children Infants and young children