• 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.
• Intraosseous needle (18 or 20 gauge) or bone
marrow aspiration needle.
• Povidone, chlorhexidine, and alcohol wipes.
• Extension tubing.
• 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
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.
• Sanitize or wash your hands thoroughly and don
• 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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