Intraosseous Line Placement - Curbside
Intraosseous Line Placement
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Urgent/emergent situations where venous access cannot be achieved quickly or reliably
Exclusion Criteria
  • Osteogenesis imperfecta or osteopetrosis
  • Patients with right-to-left intracardiac shunts (risk of fat/bone-marrow emboli)

Consider central line or other vascular access

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Evidence
Total Notes: 7
Evidence

1 Intraosseous lines

The intraosseous line is the vascular access of choice for both adults and children when emergent access is needed for resuscitation. Long bones have a bony matrix that supports veins that drain to the medullary sinus even in a patient in shock or cardiovascular collapse. Accessing this space through the bony cortex allows the provider the ability to deliver fluids, medications and conduct diagnostic studies even when vascular access is impossible to too time constricted to obtain.

Studies have shown that IO access is much quicker and more likely to be successful than emergency central venous access or venous cutdown. Nearly all resuscitation medications and fluids can be delivered through IO access and nearly all ages of patients may have an IO safely placed. In the past adults were less likely to have an IO placed, however, new literature suggests that IO placement is well tolerated, more successful and time saving in adult resuscitation.



References:
  1. Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use.
    Tobias JD, Ross AK
    Anesth Analg. 2010;110(2):391.
  2. Intraosseous infusion: a review of methods and novel devices.
    Blumberg SM, Gorn M, Crain EF
    Pediatr Emerg Care. 2008;24(1):50.
  3. Intraosseous access.
    Luck RP, Haines C, Mull CC
    J Emerg Med. 2010;39(4):468.
  4. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
    Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL
    Circulation. 2010;122(18 Suppl 3):S876.
  5. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
    Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ
    Circulation. 2010;122(18 Suppl 3):S729.
  6. The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children.
    Banerjee S, Singhi SC, Singh S, Singh M
    Indian Pediatr. 1994;31(12):1511.
  7. Prehospital intravenous access in children.
    Lillis KA, Jaffe DM
    Ann Emerg Med. 1992;21(12):1430.
  8. Five-year experience in prehospital intraosseous infusions in children and adults.
    Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS
    Ann Emerg Med. 1993;22(7):1119.
  9. A prehospital model of intraosseous infusion.
    Fuchs S, LaCovey D, Paris P
    Ann Emerg Med. 1991;20(4):371.
  10. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial.
    Reades R, Studnek JR, Vandeventer S, Garrett J
    Ann Emerg Med. 2011 Dec;58(6):509-16.
  11. Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study.
    Leidel BA, Kirchhoff C, Braunstein V, Bogner V, Biberthaler P, Kanz KG
    Resuscitation. 2010;81(8):994.
  12. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study.
    Leidel BA, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz KG, Braunstein V
    Patient Saf Surg. 2009;3(1):24.

2 Site placement

At least one study has looked at the optimal site placement for the first attempt at IO (done in the setting of prehospital cardiac arrest). Proximal tibia placement was faster and less likely to be lost than proximal humerus. It is also acceptable in all age groups. If a patient has a severe wound over a potential IO site, the bond is fracture or bone has already had an attempt at cannulation, a different site will be preferred.



References:
  1. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial.
    Reades R, Studnek JR, Vandeventer S, Garrett J
    Ann Emerg Med. 2011 Dec;58(6):509-16.
  2. Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration.
    Orlowski JP
    Pediatr Clin North Am. 1994;41(6):1183.
  3. Intraosseous drug administration in children and adults during cardiopulmonary resuscitation.
    Buck ML, Wiggins BS, Sesler JM
    Ann Pharmacother. 2007;41(10):1679.

3 Manual needle technique

The manual needle technique has the advantage of allowing placement without any need for battery power. They are also inexpensive. However, manual needles require more expertise than other techniques and cannot be used in patients greater than 6 years as the cortical bone of the proximal tibia becomes too thick for easy cannulation of the bone marrow (distal tibia is an alternative). Manual needles are successful 76 to 100 percent of the time (50 to 67 percent greater than one year old). Their median time to insertion was 38 seconds.



References:
  1. Videos in clinical medicine. Intraosseous catheter placement in children.
    Nagler J, Krauss B
    N Engl J Med. 2011;364(8):e14.
  2. Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration.
    Orlowski JP
    Pediatr Clin North Am. 1994;41(6):1183.
  3. Intraosseous extravasation complication reports.
    Simmons CM, Johnson NE, Perkin RM, van Stralen D
    Ann Emerg Med. 1994;23(2):363.
  4. Five-year experience in prehospital intraosseous infusions in children and adults.
    Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS
    Ann Emerg Med. 1993;22(7):1119.
  5. Intraosseous access in the setting of pediatric critical care transport.
    Fiorito BA, Mirza F, Doran TM, Oberle AN, Cruz EC, Wendtland CL, Abd-Allah SA
    Pediatr Crit Care Med. 2005;6(1):50.
  6. Intraosseous devices: a randomized controlled trial comparing three intraosseous devices.
    Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB
    Prehosp Emerg Care. 2010;14(1):6.
  7. Prehospital intraosseous infusion by emergency medical services personnel: a prospective study.
    Seigler RS, Tecklenburg FW, Shealy R
    Pediatrics. 1989;84(1):173.

4 Battery-powered driver

Battery-powered drivers have needles that are available for all ages, easy to learn, have been shown to have shorter insertion times with greater success. Secondary to these findings this device has become the preferred technique in many hospitals and pre-hospital settings. Battery-powered devices are successful 87 to 97 percent of the time. Their median time to insertion was less than 10 seconds.



References:
  1. Videos in clinical medicine. Intraosseous catheter placement in children.
    Nagler J, Krauss B
    N Engl J Med. 2011;364(8):e14.
  2. Intraosseous infusion: a review of methods and novel devices.
    Blumberg SM, Gorn M, Crain EF
    Pediatr Emerg Care. 2008;24(1):50.
  3. Intraosseous devices for intravascular access in adult trauma patients.
    Day MW
    Crit Care Nurse. 2011;31(2):76.
  4. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients.
    Horton MA, Beamer C
    Pediatr Emerg Care. 2008;24(6):347.
  5. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.
    Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A
    J R Army Med Corps. 2007;153(4):314.
  6. Consecutive field trials using two different intraosseous devices.
    Frascone RJ, Jensen JP, Kaye K, Salzman JG
    Prehosp Emerg Care. 2007;11(2):164.

5 Bone injection gun

Bone injection guns are spring loaded devices that insert an IO needle to a predetermined depth with in bone. They can be used in patients older than one year of age. Bone injection devices are successful 45 to 91 percent of the time. Their median time to insertion was 49 seconds.



References:
  1. Intraosseous infusion: a review of methods and novel devices.
    Blumberg SM, Gorn M, Crain EF
    Pediatr Emerg Care. 2008;24(1):50.
  2. Intraosseous devices for intravascular access in adult trauma patients.
    Day MW
    Crit Care Nurse. 2011;31(2):76.
  3. Intraosseous devices: a randomized controlled trial comparing three intraosseous devices.
    Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB
    Prehosp Emerg Care. 2010;14(1):6.
  4. Intraosseous infusion using the bone injection gun in the prehospital setting.
    David JS, Dubien PY, Capel O, Peguet O, Gueugniaud PY
    Resuscitation. 2009;80(3):384.
  5. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.
    Schwartz D, Amir L, Dichter R, Figenberg Z
    J Trauma. 2008;64(3):650.
  6. Prehospital intraosseus access with the bone injection gun by a helicopter-transported emergency medical team.
    Gerritse BM, Scheffer GJ, Draaisma JM
    J Trauma. 2009;66(6):1739.

6 Confirm placement

Once the IO has been placed the provider should confirm that the needle tip is within the bone marrow. This can be accomplished by aspirating bone marrow from the line. It should be noted that bone marrow may not always be aspirated even in a properly placed IO. If the IO needle will not stand on its own, it is unlikely that it is in the proper position. If infusion of fluids causes swelling or induration indicative of extravasation, then the needle is likely outside of the bone marrow space. In addition to these methods, fluoroscopy and ultrasound have been shown to identify properly placed IOs.



References:
  1. Intraosseous access.
    Luck RP, Haines C, Mull CC
    J Emerg Med. 2010;39(4):468.
  2. Intraosseous needle: use of the miniature C-arm imaging device to confirm placement.
    Garcia CT, Cohen DM
    Pediatr Emerg Care. 1996;12(2):94.
  3. Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation.
    Tsung JW, Blaivas M, Stone MB
    Resuscitation. 2009;80(6):665.

7 IO use

Most diagnostic studies (including type and screen) obtained from the bone marrow are accurate. However, there may be inaccuracies for WBC count, oxygenation, potassium, AST, ALT and ionized calcium. Once, medications are infused into the bone marrow, subsequent laboratory tests may be inaccurate.

IO lines should be viewed as temporary and venous access should be obtained as soon as possible and the IO removed. IOs in place longer than 24 hours have been associated with osteomyelitis. Fractures have been associated with IO placement as has compartment syndrome from infiltration. Fat and bone marrow emboli can occur with IO placement, but their consequence is poorly understood. Despite these risk, IO placement is very safe with complications occurring in less than 1 percent of patients.



References:
  1. Bone marrow aspirate as an accessible and reliable source for critical laboratory studies.
    Grisham J, Hastings C
    Ann Emerg Med. 1991;20(10):1121.
  2. Are laboratory values in bone marrow aspirate predictable for venous blood in paediatric patients?
    Ummenhofer W, Frei FJ, Urwyler A, Drewe J
    Resuscitation. 1994;27(2):123.
  3. Typing and screening of blood from intraosseous access.
    Brickman KR, Krupp K, Rega P, Alexander J, Guinness M
    Ann Emerg Med. 1992;21(4):414.
  4. Use of intraosseous blood to assess blood chemistries and hemoglobin during cardiopulmonary resuscitation with drug infusions.
    Johnson L, Kissoon N, Fiallos M, Abdelmoneim T, Murphy S
    Crit Care Med. 1999;27(6):1147.
  5. Intraosseous access in the setting of pediatric critical care transport.
    Fiorito BA, Mirza F, Doran TM, Oberle AN, Cruz EC, Wendtland CL, Abd-Allah SA
    Pediatr Crit Care Med. 2005;6(1):50.
  6. Intraosseous infusion: an alternative route of pediatric intravascular access.
    Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C
    Ann Emerg Med. 1985;14(9):885.
  7. Iatrogenic bilateral tibial fractures after intraosseous infusion attempts in a 3-month-old infant.
    La Fleche FR, Slepin MJ, Vargas J, Milzman DP
    Ann Emerg Med. 1989;18(10):1099.
  8. Amputation and intraosseous access in infants.
    Taylor CC, Clarke NM
    BMJ. 2011;342:d2778.
  9. Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis.
    Claudet I, Baunin C, Laporte-Turpin E, Marcoux MO, Grouteau E, Cahuzac JP
    Pediatr Emerg Care. 2003;19(6):397.
  10. Tibial length following intraosseous infusion: a prospective, radiographic analysis.
    Fiser RT, Walker WM, Seibert JJ, McCarthy R, Fiser DH
    Pediatr Emerg Care. 1997;13(3):186.
  11. The safety of intraosseous infusions: risks of fat and bone marrow emboli to the lungs.
    Orlowski JP, Julius CJ, Petras RE, Porembka DT, Gallagher JM
    Ann Emerg Med. 1989;18(10):1062.
  12. Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation.
    Fiallos M, Kissoon N, Abdelmoneim T, Johnson L, Murphy S, Lu L, Masood S, Idris A
    Am J Med Sci. 1997;314(2):73.