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  • • Emergent temporary vascular access during cardiopulmonary resuscitation or during the treatment of uncompensated shock when unable to insert an intravenous line.

    • Volume resuscitation.

    • Administration of blood and blood products.

    • Administration of fluids and electrolytes.

    • Administration of medications.

    • Infusion of inotropes and pressors.

    • Sampling of blood and bone marrow.




  • • Do not insert in a recently fractured bone.

    • Do not insert through an infected site.

    • Osteogenesis imperfecta.

    • Osteopetrosis.




  • • Osteoporosis or osteopenia.

    • Cystic bones.

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• Caution: All equipment must be latex free.

  • • Intraosseous needle (18 or 20 gauge) or bone marrow aspiration needle.

    • Povidone, chlorhexidine, and alcohol wipes.

    • Gauze.

    • Tape.

    • Extension tubing.

    • T-connector.

    • Syringe.

    • Gloves.

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• Each of the risks listed is < 1%.

  • • Infection.

    • Injury to growth plate.

    • Bone fracture.

    • Hematoma.

    • Extravasation.

    • Compartment syndrome.

    • Severe vasoconstriction if vasoactive substances extravasate.


  • • Do not place hands under the site of insertion.

    • Avoid administration of bone marrow–suppressing drugs.

    • Avoid prolonged use. Replace with an intravenous line after the patient is stabilized.

    • A properly placed unsupported needle will remain upright.

    • Fluid should flow freely through the needle, and the line should flush without resistance.


  • • Introduce yourself to the parents and the patient.

    • Explain the procedure.

    • Choose the most appropriate site.

    • Inject local anesthetic if the patient is conscious.


  • • Support the site of insertion over a firm surface.

    • Hold the extremity above and below the insertion site.

    • Position the patient with the selected site closest to where you are standing.


Recommended Sites of Intraosseous Insertion




  • • Medial flat surface of the anterior tibia 1–2 cm below the tibial tuberosity.

    • Direct the needle caudally to avoid the growth plate.

    • Alternate site is the distal femur.




  • • Medial flat surface of the anterior tibia 1–2 cm below the tibial tuberosity.

    • Alternate site is the distal tibia.




  • • Medial flat surface of the anterior tibia.

    • Alternate sites include the following:

    • • Distal tibia proximal to the medial malleolus.

      • Distal femur.

      • Anterior superior iliac spine.

      • Posterior superior iliac spine.

      • Iliac crest.


  • • Sanitize or wash your hands thoroughly and don gloves.

    • Use universal precautions or isolation precautions as appropriate.

    • Cleanse the site with antiseptic solution.

    • Support the leg on a firm surface and have an assistant support the leg above and below the insertion site.

    • Ensure no hand is under the site.


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