Intraosseous Line
Choose Needle length (15, 25, 45mm) based on soft tissue thickness [Yellow for fat!]
Contraindications
Contraindications
- Fracture/trauma
- Previous IO attempt on same bone <48h
- Overlying infection
- Proximal circulatory compromize
- Site specific: Inability to immobilize site (eg. unable to keep patient arm on chest due to chest compressions)
Landmark
Landmark
- Proximal Tibia (children)
- Immobilize leg
- Identify tibial tuberosity and move onto tibial plateau:
- Children move 2cm inferior and 1cm medial
- Adults move 1cm inferior and 2cm medial
- Insert 90 degrees (perpendicular) to bony plane
- Proximal Humerus (adults)
- Immobilize arm on chest (internal rotation)
- Alternative: Extend elbow along side of body and exaggerated hyperpronation/internal rotation of arm
- Avoid biccipital groove/tendon
- On anterolateral shoulder identify surgical neck of humerus
- Insertion site 1cm above neck of humerus
- Insert 90 degrees (perpendicular) to skin
- Immobilize arm on chest (internal rotation)
- Other options: distal tibia (1-2cm superior to medial malleolus), distal femur (1-2cm above patella in young children)
Procedure
Procedure
- Consider local anesthesia for skin/periosteum
- Consider cleaning site and let dry
- Stabilize site (secure limbs well)
- Insert needle through soft tissue until hits bone
- Power drill with light and steady pressure until feel "give/pop"
- Do not push, allow drill to do the work
- Careful in children, as often IO inserted through bone
- Remove stylet (by turning counter-clockwise)
- Consider analgesia (2-2-2) = 2mL of 2% lidocaine mixed into 10mL NS flush syringe, wait 2 minutes for analgesia, may repeat twice PRN
- Flush slowly to prevent fat embolism
- Secure catheter hub with stabilizer or stacked gauze and tape
- Dislodgement can cause leak
Confirm placement
Confirm placement
- Firm placement of needle in bone
- Blood in stylet
- Return of bone marrow
- Smooth fluid flush
- Watch for extravasation
- Check flow while squeezing soft tissue around site of placement (to check if infusing in soft tissue)
- Consider POCUS
If failure, place another IO (success-pass success rate almost 100%)!
Removing the IO needle
- Use a syringe with a luer lock to screw on IO needle
- Holding limb in one hand and syringe in other can pull out as you rotate clockwise