Chapter 17 – Intraosseous Access Techniques


Intraosseous (IO) infusion is based on the principle that medullary veins of long bones remain patent during shock and hypovolemia.

Chapter 17 Intraosseous Access Techniques

Angelica Loza-Gomez and Aaron Strumwasser


  • Intraosseous (IO) infusion is based on the principle that medullary veins of long bones remain patent during shock and hypovolemia.

  • Emergent medical and traumatic conditions may make traditional IV access difficult in patients secondary to obesity, edema, burns, or history of IV drug abuse.

  • The success rates of IO placement with a battery-powered device are higher than 95% and normally achieved in less than one minute.

  • IO access allows for fluid resuscitation, blood product delivery, and life-saving drug administration, with similar efficacy to IV access. Peripheral blood sampling can be performed via IO cannulation.

  • IO access provides a route for all Advanced Cardiac Life Support (ACLS) fluids and drugs, at the same doses prescribed for traditional IV access. However, adenosine, antibiotics, and phenytoin require adjusted dosing for IO administration.

  • Infusion rate under pressure with infusion pump, pressure bag, or manual pressure range from 1,000 ml/hr to 5,000 ml/hr, but will vary among patients and anatomical sites. In general, gravity alone will not generate an adequate flow rate for resuscitation.

  • IO catheters should be replaced with a venous line as soon as possible. Catheters that stay in place beyond 24 hours are associated with an increased risk of osteomyelitis.


  • IO access is useful in resuscitating the severely injured or critically ill patient when peripheral access is unobtainable.

  • IO access may be an acceptable first attempt venous access in patients in full cardiopulmonary arrest or severe shock. In these cases, IO cannulation and peripheral venous access may be attempted simultaneously.

  • IO access may be used for drug, fluid, or blood product administration, and some blood draw samples.

Contraindicatio ns

  • IO placement is contraindicated in the presence of extremity fractures. A fractured bone leads to direct extravasation of fluids and medications into the surrounding tissues.

  • Infection at a bony insertion site should prompt the provider to choose a different site of insertion in order to avoid spreading sepsis or osteitis.

  • In general, IO access should be avoided in severe osteoporosis and genetic or acquired bone diseases.

  • Extremity sites with severe soft tissue trauma, burns, or compartment syndrome should be avoided.


  • IO catheters come in two forms: (1) manual needles and (2) battery-powered driver.

  • The choice of device (manual or battery-powered) is based on patient age, bony site, institutional availability, and physician preference.

    1. o In infants under one year of age, consider manual needles or battery-powered devices.

    2. o In children one year of age or older, adolescents, and adults, consider a battery-powered device.

  • The needle size depends on the age and weight of patient, along with the commercially available kits.

  • The needles are color-coded according to age and weight.

Anatomic Sites and Patient Preparation


  • Ensure the IO device chosen is intended for sternal placement.

  • Patients are positioned supine.

  • The sternal notch is palpated and a site selected for insertion should be 2 cm distal, within the manubrium. Some manufacturers provide a device-specific guide for sternal placement to assist with site identification and cannulation (Figure 17.1).

Figure 17.1 Sternal insertion site. The manual insertion site is 2 cm distal to the sternal notch, within the manubrium.

Proximal Humerus

  • The patient should be supine, with the elbow adducted and arm internally rotated across the torso. When positioned correctly the palm overlies the umbilicus. This will minimize the likelihood of brachial plexus injury.

  • The humerus is then palpated and the greater tuberosity identified as the insertion point, 1 to 2 cm above the surgical neck and lateral to the intertubercular groove (also known as the bicipital groove) (Figure 17.2).

  • Insert and aim the needle set at a 45-degree angle downward. It might be useful to aim the needle tip toward the inferior lateral border of the scapula.

  • Gently drill approximately 2 cm or just before the hub overlies the skin in adults. For children, stop when you feel a “give” or a “pop.”

  • This anatomical location should be cannulated preferably with the battery-powered device.

Figure 17.2 Humerus insertion site. The greater tuberosity is identified, about 2–3 cm inferior to the acromion process.

Proximal Tibia

  • The patient should be supine with the hip extended and the knee slightly flexed, if possible.

  • Assistants should stabilize the lower leg manually and the knee, supported by towel rolls.

  • The tibial tuberosity is palpated just below the knee.

  • The insertion site is two fingerbreadths (2 cm) distal to the tibial tuberosity and two fingerbreadths (2 cm) medial on the flat portion of the tibia.

  • Aim the needle set 90 degrees to the flat surface of the tibia (Figure 17.3).

Apr 22, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 17 – Intraosseous Access Techniques

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