Intraosseous Needle Insertion

Kalpesh Patel, MD

Dept. of Pediatric Emergency Medicine

November 22, 2006

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Objectives

Understand the history of intraosseous needles (IO) Understand the indications, risks, and benefits of IO

needle insertion Learn to perform:

• IO needle insertion at various locations using the manual insertion method

• IO needle insertion using new techniques

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History

Earliest reference to IO use was in 1922 First theraputic use in humans was reported in 1934 Popularized in the 1940’s for rapid access Used widely until 1950’s when the plastic catheter

was devised Reemerged in mid 80’s for resuscitation where IV

access was difficult Since then, pediatric use has become more

accepted Now used as the standard of care for emergency

access in both pediatrics and adults

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Physiology

The marrow cavity is in continuity with the venous circulation and functions as a non-collapsable venous plexus

Sinusoids serve as transport to the central venous channel exiting as nutrient and emissary veins

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Physiology

The onset of action and drug levels during CPR using the IO route are similar to those given IV • Used to infuse fluids,

blood products, and drugs

• Can take mixed venous blood samples for labs such as crossmatch, bedside tests, etc.

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Indications

When vascular access is needed in life-threatening situations

When attempts at standard venous access fail (three attempts or 90 seconds) or in cases where it is likely to fail and speed is of the essence.

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Contraindications

Femoral fracture on the ipsilateral side Do not use fractured bones Do not use bones with osteomyelitis Osteogenesis Imperfecta Osteopetrosis

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Types of IO Needles

Cook IO Needle

Jamshidi IO Needle

Illinois Sternal Iliac NeedleSur-Fast IO Screw Tip

Needle

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Equipment Required

Antiseptic prep solution Local Anesthetic (optional in the moribund patient) IO Needles

• 18-20 gauge spinal needle can be used as an alternative

• In a pinch, any needle can be used, but may get clogged with cortical bone without stylet or trochar

Syringe Flush solution Gauze pads and tape

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Locations of Insertion

3 most common locations:• Proximal Tibia

Medial side, 1-2 cm below and avoiding the tibial tuberosity

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Locations of Insertion

Distal Femur• Femur is triangular shaped.

Insert needle 1-2 cm proximal to the superior border of patella and medial or lateral to anterior ridge

Distal Tibia• 1-2 cm proximal to the

medial malleolus in the center of the bone

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Locations of Insertion

In older children and adults:• Iliac crests, preferably

Anterior Superior Iliac Spine

• Sternum

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Technique for Manual Insertion

Prep the site Inject 1-3 ml of lidocaine into the skin and down to

the periosteum (optional when time does not permit this)

Grasp needle in dominant hand and place it on the site with the needle pointing away from the joint

Pinch needle with thumb and forefinger and allow the hub to rest in the palm of your hand

DO NOT PLACE YOUR OTHER HAND BENEATH THE SITE

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Technique for Manual Insertion

Use firm downward pressure and rotate the needle back and forth

Feel for a sudden decrease in resistance or a popping sound and advance the needle a few millimeters

Remove the trochar or stylet and aspirate marrow

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Technique for Manual Insertion

Infuse fluid to determine ease of flow and no extravasation in to soft tissues around the insertion site

Secure the needle with goal post taping to allow visualization of the site

If the needle fails, then insert into a new bone because fluid will leak from the failed site

IO Insertion

http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=1528&id=1347

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Complications

Through and through penetration• Extravasation of fluids or medications into subcutaneous

tissue Compartment syndrome

Subcutaneous abscess/skin necrosis Osteomyelitis

• When an aseptic technique is used, the incidence of osteomyelitis is less than 1%

Bacteremia Epiphyseal injury and fracture (especially in neonates) Fat Embolus Bent needle Complications are reported to occur in <1% of cases

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New Methods

F.A.S.T -1 system Bone Injection Gun (BIG) EZ-IO Drill

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F.A.S.T. -1 Sternal Intraosseous Device

First Access for Shock and Trauma

Created for insertion into manubrium of adult sternum

May be used in older children

http://www.pyng.com/movies/iousemovie.html

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Bone Injection Gun

Spring loaded catheter injected into place at a preset depth

Comes in Adult and Pediatric sizes

Establishes access within 1 minute

BIG, The Movie

http://www.ps-med.com/big/description_big01.html

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EZ-IO

A battery powered electric drill which places the needle quickly into place

EZ-IO Insertion

http://www.vidacare.com/Products/index_4_29.html

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Aftercare

IO’s are emergency lines and every effort should be made to place an intravenous line after initial resuscitation

IO’s should ideally be removed within 6-12 hours All IO’s will eventually start to leak IO’s can stay in for up to 48-72 hours, but after 24

hours the risk of osteomyelitis increases dramatically

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Summary

IO’s are essentially equivalent to IV access Should be used for emergency access Many types of needles exist, but Jamshidi style is

preferred by most users Preferred insertion sites include proximal or distal

tibia, or distal femur, but in older children, iliac crests and sternum can be considered

New devices are emerging, but are not standard of care in pediatrics yet

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Questions?