OBJECTIVES & QUESTIONS
Indications & Contraindications
What are the indications for intraosseous access?
- In general, indications for both adults and children include:
- Failure to gain intravenous access in a resuscitation, trauma or peri-arrest setting allowing stabilization and facilitation of definitive, long-term intravenous access
- Failure to gain access in a life-threatening situation within a short period of time
• Specific recommendations include:
Organisation
Recommendation
Adults
Resus Council
'Route of choice during cardiac arrest if IV access is not possible or associated with a delay in the first 2 minutes of resuscitation'
Adults
European Resus Council
'If intravenous access is difficult or impossible'
Adults
NICE
'For circulatory access in patients with major trauma in hospital settings: where peripheral intravenous access fails while central access is being achieved'
Children
Advance Life Support Group
'Recommended technique for circulatory access in paediatric cardiac arrest. Indicated if other attempts at venous access fail or will take longer than 1 minute'
Children
European Resus Council
'Any case, in critically ill children, if attempts at establishing intravenous (IV) access are unsuccessful after one minute'
How long can intraosseous access be used for?
- Manufacturers’ recommended maximum length of time for IO needles to stay in situ is 24 hours
- Should only be used as a temporizing measure and definitive longer-term access should be sought following insertion
What are the contraindications to intraosseous access?
- Risk to the clinician (e.g. lack of patient compliance).
- Fracture in target bone (compartment syndrome risk)
- Attempt on target bone within 48 hours
- Overlying site infection
- Previous surgery near the insertion site (caution plates or implants)
- Severe obesity or disrupted anatomical landmarks
- Osteopetrosis (fracture risk)
- Osteogenesis Imperfecta
- Requirement for MRI (made using tungsten steel and are not MRI compatible)
Complications
What are the complications of intraosseous access?
- Overall rate of serious complications is of (<1%)
Vascular Complications
- Extravasation (most common)
- Compartment syndrome (if large extravasation or infiltration goes unnoticed)
- Embolism (air or fat)
Osseous Complications
- Fracture of the target bone
- Necrosis of epiphyseal plate
- Osteomyelitis (0.6% - associated with use of hypertonic solutions)
- Penetration through posterior cortex
Other
- Pain on insertion
- Skin necrosis
- Cellulitis and local infection
- Injury to local structures
Uses (Samples, Drugs & Infusions)
What can an intraosseous needle be used for?
- Obtaining samples for pathology testing
- Administration of drugs
- Infusion of fluids and blood products
Which tests can be performed on samples obtained from an intraosseous needle?
- There is good consensus that marrow obtained following IO insertion can be used for:
- Point of care glucose testing
- Microbiological cultures
- Institutions vary in the ability to use the aspirate for other pathology investigation depending upon equipment – should always be confirmed with laboratory and labelled
- Point of care testing is feasible but caution should be taken when analysing results as there can be significant variation between intraosseous and arterial/venous values:
- Recent systematic review suggests weak evidence for agreement of correlation
- Each test shows differing levels of correlation between IO and venous samples
Correlate Well
Correlate Poorly
Hemoglobin
Chloride
Urea
Creatinine
Albumin
Chloride
Urea
Creatinine
Albumin
WBCs (significantly higher in marrow samples
Platelets
Serum CO2
Sodium
Potassium
Calcium
Platelets
Serum CO2
Sodium
Potassium
Calcium
Which drugs can be administered via the intraosseous route?
- Consensus is that all drugs required for emergency situations can be given via the intraosseous routes:
- Includes any drugs given peripherally or centrally
- The only exception is bretylium (anti-arrhythmic)
- Achieves pharmacokinetics comparable with central venous access
- Intraosseous dosages are typically identical to IV dosages.
What rates of fluid can be achieved through the intraosseous route?
- Fluid must be infused under pressure via the IO route:
- An IV pressure bag is usually required to generate optimal flows
- Different rates can be achieved according to the insertion site:
- Flow rates are dependent on performing a syringe flush prior us
- The sternal site provides the fastest flow but is not routinely recommended
- Estimates from a study with fluid infused at 300mg pressure suggest flows of:
Site
Flow Rate
Humerus
5L/hour
(~80ml/min)
(~80ml/min)
Tibia
1L/hour
(~15ml/min)
(~15ml/min)
Sites
What are the possible sites for intraosseous needle insertion in adults and children?
- In adults, the recommended first-line insertion site is the proximal humerus
- It carries the advantages of:
- Fast flow rates (5L/hour)
- Lower insertion and infusion pain
- Sternal insertion is not routinely recommended due to risk of serious complications (fracture, haemothorax, and cardiac / large-vessel injury)
- Possible sites for insertion include:
Adults
- Proximal Humerus (first line)
- Proximal Tibia
- Distal Tibia
Children
- Distal Femur
- Proximal Tibia
- Distal Tibia
How do you locate the sites for insertion in adults?
Proximal Humerus
- Place the hand across the abdomen, adducting the elbow and internally rotating the shoulder
- Palpate deeply up the humerus to the surgical neck (the spot where the “ball” meets the “tee”)
- Insertion site: 1-2cm above the surgical neck, on the most prominent aspect of the greater tubercle of the humerus
Proximal Tibia
- Extend the leg
- Insertion site: approximately 2 cm below the patella and approximately 2 cm medial to the tibial tuberosity, along the flat aspect of the tibia.
Distal Tibia
- Palpate the anterior and posterior borders of the tibia to assure insertion site is on the flat centre aspect of the bone
- Insertion site: approximately 3 cm proximal to the most prominent aspect of the medial malleolus
How do you locate the sites for insertion in children?
Distal Femur
- Place the hand across the abdomen, adducting the elbow and internally rotating the shoulder
- Palpate deeply up the humerus to the surgical neck (the spot where the “ball” meets the “tee”)
- Insertion site: 1-2cm above the surgical neck, on the most prominent aspect of the greater tubercle of the humerus
Proximal Tibia
- Extend the leg
- Insertion site: approximately 2 cm below the patella and approximately 2 cm medial to the tibial tuberosity, along the flat aspect of the tibia.
Distal Tibia
- Palpate the anterior and posterior borders of the tibia to assure insertion site is on the flat centre aspect of the bone
- Insertion site: approximately 3 cm proximal to the most prominent aspect of the medial malleolus
Devices & Needles
What devices are available for achieving intraosseous access?
Device
Comments
Image
Standard IO Needle
- Manual device - limited to paediatric use due to force required
- Adjustable guards help control depth of needle insertion
- Sharp lancet point facilitates entry to bone and have a luer lock to connect to standard syringe and infusion sets
Bone Injection Gun (BIG)
- Spring loaded device - uses a “position and press” mechanism to facilitate insertion
- Colour coded blue for adults and red for children
- Typically used at the proximal tibia
- Endorsed by the Resus Council UK
EZ-IO
- Drill-based system consisting of separate drill and needles
- Needles colour coded and available in 3 sizes for different patient sizes
- Has a uniquely designed needle tip that drills a hole in the bone the same size as the needle to minimise risk of dislodgement
- Endorsed by the Resus Council UK
- Most commonly used device in clinical practice and research in the UK
What size EZ-IO needles are available?
Red
15mm
3-39kg
Typically used in infants and very small children
Blue
25mm
40kg or over
Typically used in children and adults
Yellow
45mm
40kg or over
Typically used in larger adults and for humeral insertion
How do you determine the correct size EZ-IO needle to use?
- To ensure correct sizing the black lines can act as a “depth gauge” of soft tissue:
- At least one black line on the catheter must be visible above the skin when the needle tip is touching bone
- Generally the following needles are used:
Paediatrics
Paediatrics
Neonates and Small Infant:
- Proximal and distal tibia insertion
15mm
Neonates and Small Infant:
- Distal femur insertion
Children:
- Proximal humerus insertion
- Distal femur insertion
- Tibial insertion (proximal and distal)
25mm
Adults
Adults
- Tibial Insertion
25mm
- Proximal humerus insertion
- Any site with excessive overlying tissue
45mm
Procedure
How do you insert an intraosseous needle?
- Skin wipe
- Drill and needle
- Stabilizer dressing
Syringe for sample collection - Saline flush and syringe
- Connecting extension catheter
- Consider preservative-free 2% Lidocaine
- Explain procedure to patient or family when possible
- Wash hands and wear appropriate PPE
- Choose an appropriate size needle for the insertion site
- Prime the extension set with normal saline (or lidocaine if appropriate)
- Locate the appropriate insertion site and stabilise the limb
- Cleanse site using cleaning agent
- Push the needle set tip through the skin until the tip rests against the bone. The 5 mm mark must be visible above the skin for confirmation of adequate needle set length. Angle of needle depends upon the insertion site:
- Proximal humerus: Downward at approximately a 45-degree angle, aiming toward the inferolateral border of the scapula
- Other sites: 90-degree angle to the bone surface
- Squeeze the trigger, applying gentle steady pressure until:
- Adults: you feel a decrease in resistance or the hub is almost flush with the skin
- Children: you feel a ‘pop’ or give, indicating the needle has entered the medullary space
- Continue to hold the hub while twisting the stylet off the hub with counter-clockwise rotations. The needle should feel firmly seated in the bone (first confirmation of placement). Place the stylet in a sharps container
- Aspirate for blood/bone marrow (Second confirmation of placement. The inability to withdraw/aspirate blood from the catheter hub does not mean the insertion was unsuccessful.
- Place the dressing over the hub
- Attach a primed extension Set to the hub and firmly secure by twisting clockwise
- Prior to flush consider injection of 2% lidocaine for pain management in awake patients
- Flush the catheter with normal saline:
- Adults: 5–10 mL
- Children: 2–5 mL
- Deliver medication and fluids as prescribed
- Use a pressure bag for fluid infusions
- Secure the limb to prevent dislodgment:
- Proximal humerus:: secure in an adducted position
- Children: secure using a leg board
- Apply pink wristband next to current patient ID wristband
- Document time, date, rationale and any supporting information for insertion
- Continue to monitor extremity for complications on a regular basis
- Needle feels firmly seated in bone and remains upright
- Bone marrow is aspirated following insertion
- There is low resistance to injection of saline and no evidence of swelling
- Needle feels firmly seated in bone and remains upright
- Bone marrow is aspirated following insertion
- There is low resistance to injection of saline and no evidence of swelling
When is pain management required for IO insertion?
- Local anaesthesia is not normally required, particularly in unresponsive patients
- Insertion pain is generally mild using drill-based devices
- Infusion can be painful in conscious patients:
- Local anesthetic infusion can be given prior to flushing
- Systemic analgesia should be considered
How can intraosseous infusion related pain be managed?
How do you remove an IO needle?
- Remove the extension set from the needle hub
- Attach a 10 ml luer lock syringe to act as a handle
- Grasp syringe and continuously rotate clockwise while gently pulling the catheter out – do not rock or bend during removal
- Dispose of IO needle into a sharps bin
- Apply pressure to the site as needed
Bone Anatomy
Which structures does an intraosseous needle pass through?
- Skin
- Subcutaneous tissue
- Periosteum
- Cortical bone
- Cancellous bone
- Medullary cavity
What is the anatomy of a long bone?
Epiphysis
- Wider section at each end of the bone
- Filled with cancellous (spongy bone) and covered by a hard thin casing of cortical bone
- Red bone marrow fills the spaces between the cancellous bone
Metaphyis
- The neck portion of a long bone between the epiphysis and the diaphysis
- Contains the epiphyseal growth plate, the site of bone formation and long bone elongation
Diaphysis
- Shaft of the bone composed of a thick, hard cortex with a hollow interior medullary cavity
- Medullary cavity is filled with yellow bone marrow
What is the blood supply to the bone and how do drugs given via the IO route pass into the circulation?
- Drugs are delivered into the marrow cavity in cancellous bone:
- A highly vascular compartment filled with a network of venous sinusoids
- Non-collapsible even in shocked states
- Connect to a series of longitudinal ‘Haversian’ canals in cortical bone
- Contain a tiny artery and vein
- Cross-connect by a series of transverse ‘Volkmann’ canals:
- Penetrate through the hard cortex of the bone
- Connect to larger periosteal veins and onto the central circulation
