1. Intraosseous Needle Insertion
Kalpesh Patel, MD
Dept. of Pediatric Emergency Medicine
November 22, 2006

2. Objectives Understand the history of intraosseous needles (IO)
Understand the indications, risks, and benefits of IO needle insertion
Learn to perform:
IO needle insertion at various locations using the manual insertion method
IO needle insertion using new techniques

3. History Earliest reference to IO use was in 1922
First theraputic use in humans was reported in 1934
Popularized in the 1940’s for rapid access
Used widely until 1950’s when the plastic catheter was devised
Reemerged in mid 80’s for resuscitation where IV access was difficult
Since then, pediatric use has become more accepted
Now used as the standard of care for emergency access in both pediatrics and adults

4. Physiology
The marrow cavity is in continuity with the venous circulation and functions as a non-collapsable venous plexus
Sinusoids serve as transport to the central venous channel exiting as nutrient and emissary veins

5. Physiology
The onset of action and drug levels during CPR using the IO route are similar to those given IV
Used to infuse fluids, blood products, and drugs
Can take mixed venous blood samples for labs such as crossmatch, bedside tests, etc.

6. Indications
When vascular access is needed in life-threatening situations
When attempts at standard venous access fail (three attempts or 90 seconds) or in cases where it is likely to fail and speed is of the essence.

7. Contraindications Femoral fracture on the ipsilateral side
Do not use fractured bones
Do not use bones with osteomyelitis
Osteogenesis Imperfecta
Osteopetrosis

8. Types of IO Needles Jamshidi IO Needle Cook IO Needle
Sur-Fast IO Screw Tip
Needle
Illinois Sternal Iliac Needle

9. Equipment Required Antiseptic prep solution
Local Anesthetic (optional in the moribund patient)
IO Needles
18-20 gauge spinal needle can be used as an alternative
In a pinch, any needle can be used, but may get clogged with cortical bone without stylet or trochar
Syringe
Flush solution
Gauze pads and tape

10. Locations of Insertion
3 most common locations:
Proximal Tibia
Medial side, 1-2 cm below and avoiding the tibial tuberosity

11. Locations of Insertion
Distal Femur
Femur is triangular shaped. Insert needle 1-2 cm proximal to the superior border of patella and medial or lateral to anterior ridge
Distal Tibia
1-2 cm proximal to the medial malleolus in the center of the bone

12. Locations of Insertion
In older children and adults:
Iliac crests, preferably Anterior Superior Iliac Spine
Sternum

13. Technique for Manual Insertion
Prep the site
Inject 1-3 ml of lidocaine into the skin and down to the periosteum (optional when time does not permit this)
Grasp needle in dominant hand and place it on the site with the needle pointing away from the joint
Pinch needle with thumb and forefinger and allow the hub to rest in the palm of your hand
DO NOT PLACE YOUR OTHER HAND BENEATH THE SITE

14. Technique for Manual Insertion
Use firm downward pressure and rotate the needle back and forth
Feel for a sudden decrease in resistance or a popping sound and advance the needle a few millimeters
Remove the trochar or stylet and aspirate marrow

15. Technique for Manual Insertion
Infuse fluid to determine ease of flow and no extravasation in to soft tissues around the insertion site
Secure the needle with goal post taping to allow visualization of the site
If the needle fails, then insert into a new bone because fluid will leak from the failed site

16. IO Insertion

17. Complications Through and through penetration
Extravasation of fluids or medications into subcutaneous tissue
Compartment syndrome
Subcutaneous abscess/skin necrosis
Osteomyelitis
When an aseptic technique is used, the incidence of osteomyelitis is less than 1%
Bacteremia
Epiphyseal injury and fracture (especially in neonates)
Fat Embolus
Bent needle
Complications are reported to occur in <1% of cases

18. New Methods
F.A.S.T -1 system
Bone Injection Gun (BIG)
EZ-IO Drill

19. F.A.S.T. -1 Sternal Intraosseous Device
First Access for Shock and Trauma
Created for insertion into manubrium of adult sternum
May be used in older children

20. Bone Injection Gun
Spring loaded catheter injected into place at a preset depth
Comes in Adult and Pediatric sizes
Establishes access within 1 minute

21. BIG, The Movie

22. EZ-IO
A battery powered electric drill which places the needle quickly into place

23. EZ-IO Insertion

24. Aftercare
IO’s are emergency lines and every effort should be made to place an intravenous line after initial resuscitation
IO’s should ideally be removed within 6-12 hours
All IO’s will eventually start to leak
IO’s can stay in for up to hours, but after 24 hours the risk of osteomyelitis increases dramatically

25. Summary IO’s are essentially equivalent to IV access
Should be used for emergency access
Many types of needles exist, but Jamshidi style is preferred by most users
Preferred insertion sites include proximal or distal tibia, or distal femur, but in older children, iliac crests and sternum can be considered
New devices are emerging, but are not standard of care in pediatrics yet

26. Questions?