How To Do Intraosseous Cannulation, Manually and With a Power Drill

As a temporary alternative to venous catheterization when peripheral and central venous access are difficult, particularly in emergency situations (eg, shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more , cardiac arrest Cardiac Arrest Cardiac arrest is the cessation of cardiac mechanical activity resulting in the absence of circulating blood flow. Cardiac arrest stops blood from flowing to vital organs, depriving them of... read more )

Bone fracture or recent cannulation attempt; infused fluids will extravasate into soft tissues through the cortical defects

Injured inferior vena cava; use sites that drain into the superior vena cava

Infection or burn at needle-insertion site

Osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more and osteogenesis imperfecta Osteogenesis Imperfecta Osteogenesis imperfecta is a hereditary collagen disorder causing diffuse abnormal fragility of bone and is sometimes accompanied by sensorineural hearing loss, blue sclerae, dentinogenesis... read more ; bone is easily fractured during procedure

Extravasation of fluid into soft tissues (poor control during insertion results in the needle either not entering the bone; exiting the opposite cortex; or creating a too-large, leaky hole in the cortex)

Bleeding, causing compartment syndrome Compartment Syndrome Compartment syndrome is increased tissue pressure within a closed fascial space, resulting in tissue ischemia. The earliest symptom is pain out of proportion to the severity of injury. Diagnosis... read more

Infection (osteomyelitis Osteomyelitis Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute... read more in < 2 to 3% of intraosseous cannulations)

Skin sloughing

Fat embolism

Antiseptic solution (eg, chlorhexidine, povidone-iodine, alcohol)

Towels (rolled up)

Gloves

Intraosseous needles and sometimes insertion device

Syringes, 5 to 60 mL, based on anticipated need

Sterile saline, for flushes

Sterile gauze (eg, 10 cm × 10 cm squares)

IV connection tubing and fluids

Local anesthetic (1% lidocaine without epinephrine, a 25- or 22-gauge needle, a 3- or 5-mL syringe)

Intramedullary anesthetic (2% lidocaine, preservative-free IV solution)

The distal tibia is the preferred site for manual insertion. The needle is inserted on the medial surface of the tibia at the junction of the medial malleolus and the shaft of the tibia, posterior to the greater saphenous vein.

The proximal humerus is an alternate site. It has the potential advantage, during shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more or cardiac arrest Cardiac Arrest Cardiac arrest is the cessation of cardiac mechanical activity resulting in the absence of circulating blood flow. Cardiac arrest stops blood from flowing to vital organs, depriving them of... read more , of being closer to the central circulation. The insertion site is at the greater tuberosity, with the patient’s arm adducted and the palm pronated and resting over the umbilicus.

The proximal tibia can be used in adults, but because the bone is thick, a powered device is preferred for cannulation. The needle is inserted into the flat anteromedial surface 2 cm distal to the tibial tubercle.

Other sites (iliac crest, femur, radius, clavicle, calcaneus, and sternum) may be used if necessary.

In children < 6 years old, the proximal tibia is the preferred site. The needle is placed on the broad, flat anteromedial surface 1 to 3 cm distal to the tibial tubercle.

The distal femur is an alternate site. The needle is inserted 2 to 3 cm above the lateral femoral condyle, in the midline and angled 10 to 15 degrees cephalad. The thick overlying soft tissue and muscle may make it difficult to palpate the bony landmarks in this location.

For older children, the medial surface of the distal tibia 2 cm above the medial malleolus may be easier.

Position the patient supine on the stretcher.

Place a towel roll behind the knee if the proximal tibia or distal femur is to be cannulated.

For recurring medullary pain from the infusion, repeat the slow 2% lidocaine infusion and saline flush as described above, using one-half of the initial lidocaine dose every hour as needed.

Intraosseous delivery systems should be removed as soon as practical after peripheral or central IV access has been achieved and within 24 hours of insertion (ideally within 3 to 4 hours). Pull out the needle using a steady clockwise rotation. Attach a locking cap or an empty syringe to the needle hub to afford a better grip if needed.

After needle removal, apply a sterile occlusive dressing. Chlorhexidine-impregnated discs at the insertion point and transparent membrane dressings are commonly used.

When the tip of the intraosseous needle first contacts the bone surface, at least 5 mm of the needle should be visible outside the skin so that the needle tip will be able to reach the marrow cavity. If the needle does not extend that far, a longer needle may be needed.

Avoid drilling until the needle hub is flushed with, or indenting into, skin surface. This can cause damage and skin necrosis.

Rapid infusion of crystalloids (eg, normal saline) as well as infusion of viscous fluids should be done using a pressure bag, manual injection, or an infusion pump.

Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020;142(16_suppl_2):S366-S468. doi:10.1161/CIR.0000000000000916