# Intraosseous Vascular Access

## Overview

This module describes

short-term

short-term

Intraosseous lines should be removed as soon as possible, and within 24 hours.

vascular access via the intraosseous route in the setting of emergency resuscitation or urgent fluid administration, when peripheral venous access has failed.

## Indications

## Contraindications

## Patient information and consent

This procedure is often performed in critically ill patients in an emergency setting, so consent is generally implied. However, check for “Do Not Resuscitate” (DNR) orders, “Not For Max” orders, or living wills that specify that no resuscitation may be performed. In awake patients, seek informed consent.

### How do I explain this procedure?

“I need to place a needle into the marrow of a long bone so that we can give you fluids or medication. This route works the same as for a drip in your arm, but is much faster in urgent situations.”

### What can my patient expect?

“I’m going to clean the area where the needle will go in and give you an injection so that you will not feel pain. Then I will pierce the bone using a special device. The needle will stay in your bone only for as long as it is absolutely necessary, definitely less than a day. I will connect tubing to the needle so that we can give you medications and fluids.”

### What is my patient’s role?

“Let me know if you have any bone diseases like osteoporosis. Fearing blood or needles is normal, but tell me if you have fainted from it. Stay still when I insert the needle, and let me know if at any point you have severe pain or any strange sensations.”

## Preparation

### Documentation

### Equipment

## Site & Positioning

The proximal tibia is the

site of choice

site of choice

Other potential sites include:
1. The humeral head (arm inwardly rotated with hand placed on abdomen), 2 cm above the surgical neck
2. The sternum 1 cm below the sternal notch
3. The distal femur 1 cm proximal and 1-2 cm medial to the patella with the leg straightened
4. The distal tibia 2 cm proximal to the medial malleolus on the flat portion of the tibia

Not all devices may be used to access all these sites. Check the device manual.

in most patients, particularly paediatric patients. Position the leg slightly bent, supported by a towel roll. Palpate the tibial tuberosity and insert the needle 1-2 finger-breadths distal, perpendicular to the flat aspect of the tibia.

## Procedure

Follow medical asepsis with non-sterile gloves. In non-emergency settings, use medical asepsis with sterile gloves.

## Troubleshooting

I have a paediatric patient. There is no intraosseous needle or device.

Use a paediatric spinal needle. Hold the needle with your finger and thumb along the shaft, and the hub resting against your palm for good traction. Insert using a corkscrewing motion.

I can’t aspirate any bone marrow.

Replace the stylet. If you are too shallow, advance a few mm and try to aspirate. If you have inserted almost up to the hub of the needle, you may need to withdraw a few mm. Remove the stylet and try aspirating again.

The drill doesn’t want to activate.

Keep the drill attached and use it as a grip to corkscrew the needle into the bone until you feel give.

## Risks

## References