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1.                  Immediate venous access for delivery of fluids, drugs or blood products in children, ages 0-7 years of age including neonates

2.                  Reliable access site for emergent or resuscitative situations where peripheral venous access is unobtainable




1.                  Open fracture at proposed insertion site

2.                  Skin infection at proposed insertion site





a.                   The preferred site for intraosseous access is in the center of the tibia, just distal to the tibial tubercle in neonates; in 6-12 month olds, insert 1 cm distal to tibial tuberosity, and in children > 1 year of age, insert 2 cm distal to the tibial tuberosity

b.                  Intraosseous access may be maintained at the same site for 96 hours




1.                  Sterile gloves, mask

2.                  Prep solution

3.                  IV solution and tubing

4.                  Disposable 16- or 18- gauge intraosseous needle OR 16- or 18 gauge spinal needle with stylet

5.                  Optional: lidocaine 1% for local anesthesia, with 25-or 27-gauge needle on a 3 cc syringe

6.                  Gauze, tape


Preprocedure patient education


1.                  Obtain informed consent

2.                  Inform patient (or parent/guardian) of the possibility of major complications and their treatment

3.                  Explain the major steps of the procedure




1.                  Assess need for placement of an intraosseous line, and obtain consent if appropriate.

2.                  Identify landmarks: tibial tubercle; don mask and sterile gloves; prepare IV tubing and fluid

3.                  Use prep solution to cleanse the skin over the insertion site

4.                  If appropriate, infiltrate skin and periosteum over insertion site with 1 cc of the lidocaine 1% solution, using the 25- or 27-gauge needle with the 3 cc syringe

5.                  Open the intraosseous needle, hold the stylet ball in the palm of your hand, and place the tip of your index finger 1- 1.5 cm from the tip of the needle

6.                  Insert the needle through the skin at the selected insertion site, and advance until you reach the periosteum of the tibia. You should be in the MIDLINE of the tibia, with the needle at a 300 angle from vertical (Figure 1)

7.                  Advance the needle through the periosteum into the bone with a screwing motion. A sudden “give” is felt when you enter the marrow cavity

8.                  Withdraw needle stylet, and attach IV tubing; open up IV flow




Figure 1: Inserting the intraosseous needle





            If IV fluid is seen extravasating from around the needle, it is not in the marrow cavity. Remove the needle and reposition it in the marrow cavity.


9.                  Secure the needle with gauze and tape


Complications, Prevention, and Management


1.                  Local hematoma or cellulitis. Apply pressure dressing for bleeding.

2.                  RARELY osteomyelitis; requires IV antibiotics.



Documentation in the medical record


1.                  Consent if obtained, and who it was obtained from

2.                  Indications and contraindications for the procedure on this patient

3.                  The procedure used including prep, and size of intraosseous needle

4.                  Any complications, or “none”

5.                  Who was notified about any complication (family, attending physician)



Items for evaluation of person learning this procedure


1.                  Anatomy of long bones, epiphyseal and metaphyseal location

2.                  Indications and contraindications for this procedure

3.                  Use of sterile procedure and Universal Precautions

4.                  Technical ability

5.                  Appropriate documentation

6.                  Understanding of potential complications and their correction