HWN Suggests

Intraosseous Lines

In my opinion, they are an incredibly logical alternative to “crash” central lines. I mean, seriously, in a scenario where a patient is coding or about to code, why in god’s name should we be farting around with a femoral line? People get stuck with needles. Arteries are inadvertently punctured. There’s a huge mess and it’s often not sterile. An IO goes in clean and easy within seconds and boom, you’ve got yourself access, and essentially central access at that. You can put pretty much anything in it...

Remember that not all lab values from an IO sample correlate with IV samples. Accurate IO labs include: hemoglobin/hematocrit, chloride, glucose, urea, creatinine, and albumin.

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  Peds IO

A small volume of 2% lidocaine can be given through the line prior to commencing the infusion to help with pain – this is slowly infused over 120 seconds, left for 60 seconds, then flushed with 2-5ml of saline.

 Feelin’ It in my Bones: A Review of Intraosseous Access in the Emergency Department

Intravascular access is often necessary in emergency care. Not only does it allow rapid and bioavailable administration of drugs, fluids, and other therapies, but it also facilitates access to blood and serum for diagnostic tests.

Articles of Interest

Lab Values from Intraosseous Blood

Intraosseous blood can be used if blood from arterial or venous puncture is not available. Discarding the first 2cc of marrow aspirated improves the accuracy of the lab results obtained. The important tests (hemoglobin/hematocrit, glucose) are reasonably accurate, as are Na, Cl, BUN, and creatinine. The use of IO blood for type and cross is not yet widely accepted by blood banks, but can be used until other blood is available.

Can we really use IO blood for analysis?

Unless someone out there can find better evidence (I could not) then we should not rely on bone marrow analysis in critically unwell patients. Although the only paper in critically unwell humans suggests that it might have a role for some variables I am unwilling to rely on a study of just 17 patients​.

Infant Intraosseous Infusion

In patients who have not developed a palpable tibial tuberosity (generally those less than three years of age), the proximal tibial site is determined by finding the location two finger widths (approximately 15–20 mm) distal to the patella and then medially along the flat aspect of the tibia. The distal tibial site is found by identifying the location two finger widths proximal to the medial malleolus and then again along the medial, flat aspect of the tibia. A good reminder is to think “big toe—IO” to ensure placement on the medial aspect of the patient’s leg.

Intraosseous (IO)

Intraosseous lines can safely remain in place for up to 24 hours and are often a bridge to either IV or Central Venous line placement.

Intraosseous (IO) Needle Length in Obese Patients

The 25 mm IO needle may not provide proper length for obtaining IO access in obese patients. Consider reaching for the 45 mm IO needle in these patients particularly if you cannot palpate the tibial tuberosity.

Intraosseous Access In Neonates, Infants, And Children

If you don’t put (not so) EZ-IOs into small kids a lot, consider using a manual IO. I personally think they are a lot harder to screw up. When I wasn’t working primarily in peds, I would use EZ-IO for adults and manual IOs for small kids (<10kg). I really like the Jamshidis* because they have an adjustable flange so you can set the maximum depth.

Intraosseous Access – History, Method and Automated Devices

Intraosseous access was first introduced in 1922, by Harvard physician Dr. Cecil K Drinker (Anson, 2014) (Reichman, 2013), and it was he who first described the bone marrow cavity as a ‘non-collapsible vein’.

Intraosseous Line Extravasation in a Pediatric Trauma Patient

The distal femur has been used extensively in pediatric IO infusions but not in adults. Though successfully used in both neonates and infants due to its large epiphysis, the distal femur is less accessible in adults due to overlying muscle.

Intraosseous Myths: What ED Docs Should Know About this IV Alternative

Awake patients do report pain, especially with infusions that create increased pressure in the intermedullary space. Recommendations for the awake patient include infusing lidocaine 2% (preservative free) over 120 seconds followed by allowing 60 seconds for the anesthetic to dwell in the IO space. In adults, the typical dose is 40 mg, and the pediatric dose is 0.5 mg/kg (maximum of 40 mg).

Intraosseus needle insertion for neonates

During the first week of life the umbilical vein is a convenient route for obtaining vascular access during emergencies. The intraosseous (IO) route provides an option for establishing rapid venous access in an emergency after that time.

Intravenous and Intraosseous Access in Infants and Children

The flat surface of the anteromedial proximal tibia is easily accessible given the paucity of overlying tissue, making it the most commonly accessed site. Insert the needle 2 cm inferior (distal) to the tibial tuberosity to avoid the epiphyseal plate in children.

Pediatric IO: 5 things I didn’t learn in paramedic school

The IO is no longer just my Hail Mary access in cardiac arrest. I now consider it on any patient without vascular access if a delay in fluid or drugs could be harmful.

Sternal IO

The new FASTResponder Sternal Intraosseous Device and FASTTactical Sternal Intraosseous Device from Pyng Medical gives emergency care providers the critical ability to easily establish vascular access when peripheral intravenous access fails.

Trick of the Trade: Squeeze test for confirmation of IO placement

There are already multiple methods for confirming IO placement, including return of bone marrow, visualization of blood in the stylet, firm placement of the needle in the bone, and the ability to smoothly deliver a fluid flush. Here, we suggest another method.

Vascular Access in Resuscitation: Is There a Role for the Intraosseous Route?

Although there are practical disadvantages such as needle dislodgement with the humeral intraosseous site, it may offer the benefit of higher flow rates.

Resources

Intraosseous access

Any medication/fluid that can be infused through a central line can be infused through the IO route. The IO route and the IV route are pharmacokinetically equivalent (same doses and onset).