Putting in intraosseous needle
Emergency life-saving procedure. Needle put into bone marrow space to give fluids, antibiotics and other medicines
Used when
- No IV cannula access — adults and children
- Urgent requirement for fluid and/or drug administration (eg cardiac arrest, hypovolemia, shock)
Do not use
- Side of body with definite fractured bones (compartment syndrome risk)
- Limbs with possible proximal fractures
- Sites of previous attempts
- Overlying skin infection
- Through burnt skin
- Person with osteogenesis imperfecta (brittle bone disease)
- Person with osteopetrosis (fracture risk)
Types of intraosseous needles/devices
- All devices use similar insertion sites and follow same basic principles
- Spring-loaded and drill devices are easier and quicker to use
- Drill devices use battery powered drill to put in intraosseous needle (eg EZ-IO)
- Spring-loaded devices use spring to put in intraosseous needle (eg FAST1, BIG)
- Traditional intraosseous needles use trocar and intraosseous needle (eg Cook, Jamshidi)
Attention
Always check manufacturer's instructions for your device. The following are basic principles only
- Do not tape over manufacturer's securing devices — follow the instructions
- Manual intraosseous needle should only be used if no other devices available
- Practice regularly on fresh chicken thighs or fresh uncooked eggs so you know how to use in emergency
- Can look frightening to parent/carer so explain what you need to do and reassure them it is standard procedure
- If person very unwell — local anaesthetic not required
- If IV fluid leaks out of site you tried before — stop with firm direct pressure
Proximal tibia insertion site
- Feel for bump on the shin under the kneecap (tibial tuberosity)
- Adult — go 2cm across toward other leg (medially)
- Then 1cm down for drill (eg EZ-IO) and manual devices — Figure 4.18
- If using spring loaded device (eg BIG) then go 1cm up — Figure 4.19
- Child — go 1cm under bump, then 1cm across toward other leg (medially) — Figure 4.20
You are trying to avoid the joint
Distal tibia insertion site
- 3cm proximal to the most prominent aspect of the medial malleolus
- Place one finger directly over the medial malleolus then move — 2cm proximal
- Palpate the anterior and posterior borders of the tibia to ensure that the insertion site is on the flat central aspect of the bone
Femoral insertion site
- Anterolateral surface, 3cm above lateral condyle
Proximal humerus insertion site
- Slide thumb up the anterior shaft of the humerus until feel the greater tubercle. This is the surgical neck
- 1cm above the surgical neck is the insertion site
- The person’s hand should rest palm down on the their abdomen with the elbow abducted
- In small children the greater tubercle is poorly developed and may be impalpable
What you need
- Helper
- Clean towel
- Bluey or sterile dressing pack
- Povidone-iodine or chlorhexidine or alcohol wipes
- Sterile gloves
- Local anaesthetic (lidocaine 1%), syringe and needles if needed
- 5mL normal saline in syringe
- See-through sticky dressing
- Sterile extra gauze swabs
- IV line primed with normal saline
- Splint
What you do
- Use rolled up towel under knee to help stablise insertion site if needed
- Locate insertion site
- Lay out dressing pack and equipment
- Wash hands and put on sterile gloves
- Clean site
- Put in local anaesthetic if using
- Put in intraosseous needle — see If using drill, Spring-loaded device or Manual insertion
If using drill
- Attach correct sized needle and remove safety cap — Figure 4.21
Intraosseous needle set
- 45mm (humerus insertion or excessive tissue)
- 25mm (above 40kg)
- 15mm (3-39kg)
- Put in needle to 5mm mark — Figure 4.22 at 90° (right angle) to bone — Figure 4.23
- Operate drill until you hear the ‘pop’
- Hold needle set and remove drill — Figure 4.24
- Unscrew trocar and remove from catheter
- Secure needle with stabiliser if provided OR see Secure needle
Spring-loaded device
- Choose device
- Blue for adults — use on proximal tibia or humerus
- Red for children — use on proximal tibia
- Remove device from package, face device (in direction of arrow) away from person and user
- Wind red device to select the correct age (0–3, 3–6, 6–12 years old)
- Position gun on chosen location at 90° (right angle), hold coloured barrel firmly with non-dominant hand — Figure 4.25
- Remove safety latch — Figure 4.25 and put somewhere safe
- Position dominant hand with fingers under wings and palm over barrel — Figure 4.26. Push down firmly, have arm straight to reduce kickback
- Lift device up and off site gently, then remove trocar by twisting and pulling upward. If tight — use artery forceps
- Stabilise cannula with safety latch — Figure 4.27 Figure 4.28
Manual insertion
Always angle needle at 60° away from joint — Figure 4.29. Avoids damage to growth plates (epiphyses) in children's bones.
- Choose site — Figure 4.30
- With handle of needle in palm of your dominant hand, hold shaft of needle about 1cm from point — Figure 4.31
- Use non-dominant hand to stabilise limb — Figure 4.31. Keep bone stable and skin tight
- With handle of needle in palm of your dominant hand, hold shaft of needle about 1cm from point — Figure 4.31
- Start at 90° (right angle) to bone until needle 'bites' then angle needle at 60° away from joint. Slowly and firmly push and grind it in using clockwise and anti-clockwise screwing motion of wrist and hand
- You will feel a 'give' and a 'crunch' when needle goes through bone into marrow. Needle should now stand on its own
- Hold outer needle firmly while you take out trocar (inner needle)
- Aspirate and start bolus and medicine
- Secure needle
Aspirate and start bolus and medicine
- Aspirate blood sample if needed (often difficult) — suitable for blood culture bottles, bedside glucometers, and handheld I-STAT instruments
- Flush needle with normal saline to clear any bits of bone or marrow
- If conscious — use lidocaine (lignocaine) 1% then 5mL normal saline
- 15–30kg — 1mL lidocaine (lignocaine) 1%
- Over 30kg — 2mL lidocaine (lignocaine) 1%
- To give bolus to baby or child — use 20mL syringe to give 10–20mL as IV push
- Connect IV line — often difficult to get to run freely — use 20mL syringe as IV push
- Alternatively IV hand pumps, pressure bags or pump/syringe driver
- Flow rates at proximal humerus superior to proximal tibia
- When infusion running, carefully check above, below and behind the needle site for swelling. Swelling may mean fluid going into tissues. Stop and start again at another site
Secure needle
- Use tool supplied with device — allows for checking needle and site
- If no tool supplied or using manual insertion — secure by placing see-through dressing on either side of needle
- Splint leg