Healthcare and Medicine Reference
Box 12.1 Contraindications to insertion of IO needle
Proximal ipsilateral fracture
Previous IO attempts in same bone
Previous surgery at insertion site (e.g. sternotomy/knee
Osteogenesis imperfecta (relative)
Overlying infection (relative)
Inability to identify landmarks (e.g. obesity)
A marrow sample aspirated immediately following needle
insertion can be used for biochemical (acid-base status, glucose,
electrolytes) and/or haematological (haemoglobin, cross-match)
testing. Test accuracy reduces following continuous infusion, drug
administration and prolonged cardiac arrest.
Insertion pain due to stimulation of nociceptors in the skin
and periosteum is equivalent to that of wide-bore peripheral
intravenous access. Pain on initial infusion is due to intraosseous
vessel wall distension and may be severe. It can be reduced in the
conscious patient by the administration of 20-40 mg lidocaine
(0.5 mg/kg paediatric) through the device before commencing
Insertion site selection
The factors affecting IO insertion site selection include the type
of device being used, the age/size of the patient, the presence or
absence of contraindications to insertion (Box 12.1), and the skill
of the operator.
See Figure 12.3.
One fi ngerbreadth (1.5 cm) below sternal notch in midline (adult).
Sternal devices only.
Humerus (greater tubercle)
Adduct patient's arm, fl ex elbow and place their hand onto their
Palpate the anterior midshaft humerus. Continue palpating
Figure 12.3 Intraosseous insertion sites.
proximally up the anterior surface of the humerus until the
greater tubercle is met.
Palpate coracoid and acromion. Imagine a line between them
Proximal tibia (anteromedial surface)
Adult : two fi ngerbreadths below and medial to the tibial
Child : one fi ngerbreadth below tibial tuberosity (or two
fi ngerbreadths below patella) and then medial on fl at aspect
and drop a line approx 2 cm from its midpoint to the insertion
site (adult/older child).
Pelvis (iliac crest)
Palpate the anterior superior iliac spine (ASIS); continue postero-
laterally along iliac crest to the insertion point 5-6 cm from the
Distal tibia (medial surface)
Adult : two fi ngerbreadths proximal to the tip of the medial
Child : one fi ngerbreadth proximal to the tip of the medial
Distal femur (anterolateral surface)
3 cm above lateral femoral condyle (child).