Intraosseous Line

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

• 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
• Other options: distal tibia (1-2cm superior to medial malleolus), distal femur (1-2cm above patella in young children)

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

• 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