Intraosseous cannulation has been most used in infants and young children, but power drill and spring-loaded devices that facilitate needle insertion through thick cortical bone have increased the use of this method in adults.
The procedure is faster and more successful on first attempts than central venous catheterizations Central Venous Catheterization A number of procedures are used to gain vascular access. Most patients’ needs for IV fluid and drugs can be met with a percutaneous peripheral venous catheter. If blind percutaneous placement... read more 
and can be done without interrupting cardiopulmonary resuscitation Cardiopulmonary Resuscitation (CPR) in Adults Cardiopulmonary resuscitation (CPR) is an organized, sequential response to cardiac arrest, including Recognition of absent breathing and circulation Basic life support with chest compressions... read more . Fluids reach the central circulation as quickly as with venous infusion. Any fluid or substance routinely given IV (including medication and blood products) may be given by intraosseous infusion.
(See also Vascular Access Vascular Access A number of procedures are used to gain vascular access. Most patients’ needs for IV fluid and drugs can be met with a percutaneous peripheral venous catheter. If blind percutaneous placement... read more .)
Indications
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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 )
Contraindications
Absolute contraindications
Relative contraindications
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Infection or burn at needle-insertion site
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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
Complications
Equipment
Intraosseous needles have a stylet and usually an adjustable guard to control depth. Use a 25-mm long intraosseous needle for patients > 40 kg and a 15-mm long needle for patients < 40 kg. The needles may be available as part of a commercial kit with a powered insertion device similar to a cordless screwdriver/drill.
Optional equipment (if patient is conscious):
Relevant Anatomy
Insertion sites for adults
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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.
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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.
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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.
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Other sites (iliac crest, femur, radius, clavicle, calcaneus, and sternum) may be used if necessary.
Insertion sites for children
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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.
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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.
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For older children, the medial surface of the distal tibia 2 cm above the medial malleolus may be easier.
Positioning
Step-by-Step Description of Procedure
Prepare the equipment and the insertion site
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Pre-flush all IV lines and connecting tubes with normal saline.
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Put on gloves, face mask, face shield, and other personal protective equipment as needed.
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Prepare a syringe with 5 to 10 mL sterile saline in it.
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For insertion-site anesthesia, draw 3 to 5 mL of 1% lidocaine into a syringe and attach the 25-gauge needle.
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For medullary space anesthesia, draw 3 to 5 mL of 2 % preservative-free IV lidocaine into a syringe.
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Prepare the manual needle or the power drill (eg, screw the stylet securely into the needle and attach the assembly to the drill, and set any insertion depth limiters appropriately to the patient’s age and size).
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Swab the area of skin around the cannulation site with antiseptic solution, using outwardly expanding concentric circles. For children, include both the proximal tibia and distal femur in the swabbed area.
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Allow the antiseptic solution to dry for at least 1 minute.
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From this point forward, nonsterile items are forbidden from the anticipated needle-insertion site.
Anesthetize the needle insertion site
For a conscious patient:
Intraosseous (IO) needle insertion
Insert the intraosseous needle
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Palpate the insertion site with your nondominant hand.
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Stabilize the insertion site, by wrapping your nondominant hand around the extremity near the site. Do not place your hand directly behind the insertion site (to avoid self-puncture).
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Firmly hold the drill or the manual needle in your dominant hand.
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Position the needle tip at the point of insertion, perpendicular to the long axis of the bone.
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Point the needle slightly (10 to 15 degrees) away from the joint space and growth plate.
Manual insertion
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Stabilize the needle shaft at the skin surface with an index finger, to help you stop the needle's advance once the cortex is penetrated. Some needles have an adjustable plastic sleeve for this purpose.
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Advance the needle with moderate pressure and a to-and-fro rotary, coring motion. Advance along a straight path, so that the hole will be as narrow as possible (to prevent fluid extravasation).
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Stop advancing the needle when you feel the pop (sudden loss of resistance) that indicates penetration through the cortex and into the medullary space, to prevent the needle from being pushed too deeply into, or through, the bone.
Insertion using a power drill
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Penetrate the skin: Squeeze the trigger, and apply gentle pressure to penetrate the skin.
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Advance the needle: Continue to squeeze the trigger while applying steady, downward pressure against the resistance of the cortical bone.
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Immediately release the trigger and stop advancing the needle when you feel the sudden loss of resistance that indicates entry into the medullary space.
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Detach the drill from the needle, keeping the needle in place.
Confirm intramedullary needle placement
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Seeing the needle remaining upright without support is the first sign of proper needle placement.
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Remove the cap and the stylet, attach pre-flushed extension tubing, and aspirate. Free return of blood (marrow) confirms correct intramedullary placement.
If no marrow is aspirated, push 5 to 10 mL of normal saline through the needle.
If you feel resistance to the push and see or palpate local swelling (extravasation), remove the needle and cannulate another bone.
Begin intramedullary infusion
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First, instill intramedullary anesthesia (for a conscious patient): Slowly (over 2 minutes) infuse 3 to 5 mL of 2 % preservative-free IV lidocaine, stopping when the pain is gone (maximum dose 0.025 mL/kg, or 40 mg [2 mL]). Wait 1 minute, and then flush with 5 to 10 mL of normal saline.
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Begin the infusion. (IV fluid flowing freely without extravasating into surrounding tissues is another sign of correct placement.)
Dress the site
Warnings and Common Errors
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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.
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Avoid drilling until the needle hub is flushed with, or indenting into, skin surface. This can cause damage and skin necrosis.
Aftercare
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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.
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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.
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After needle removal, apply a sterile occlusive dressing. Chlorhexidine-impregnated discs at the insertion point and transparent membrane dressings are commonly used.
Tips and Tricks
References
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ATLS® - Advanced Trauma Life Support, 10th Edition - Student Course Material - Copyright© 2018 American College of Surgeons.
