Putting in intraosseous needle

Well lit area.
Wear mask.
Wear safety glasses.
Sharps disposal.
icon - sterile.jpg

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 upFigure 4.19
  • Child — go 1cm under bump, then 1cm across toward other leg (medially) — Figure 4.20

You are trying to avoid the joint

Figure 4.18 Adult — drill or manual device proximal tibia insertion site  

IO drill - position 1_labelled.jpg

Figure 4.19 Adult — spring loaded device proximal tibia insertion site

IO gun - position 1 labelled.jpg

Figure 4.20 Child — proximal tibia insertion site

IO child - tibia insertion site_labelled.jpg

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

Table 4.3 Device types 

Intraosseous drill (eg EZ-IO) and appropriate size needle kit

Spring-loaded intraosseous (eg BIG)

Manual intraosseous needle in correct size
Make sure you check inside packet for securing devices
  • Adult — blue
  • Large babies and children — red
  • Adult 12G
  • Child 16G or wide bore injection needle 16–19G
  • 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

Figure 4.21   

Inser needle into drill.

  • 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’

Figure 4.22   

IO needle for drill.

Figure 4.23   

IO drill positioned on limb, limb held steady with other hand.

Figure 4.24   

Disconnect and remove drill from inserted needle.

  • 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

Figure 4.25   

IO gun - insert 1.jpg

  • Position dominant hand with fingers under wings and palm over barrel — Figure 4.26. Push down firmly, have arm straight to reduce kickback

Figure 4.26   

IO gun - insert 2.jpg

  • 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

Figure 4.27   

IO gun insert 3.jpg

Figure 4.28   

IO gun insert 4.jpg

Manual insertion

Always angle needle at 60° away from joint — Figure 4.29. Avoids damage to growth plates (epiphyses) in children's bones.

Figure 4.29   

Point of IO needle inserted by hand is directed away from joint at 60 degree angle to bone .

Figure 4.30   

IO sites are bottom of femur (above knee), top of tibia below tibial tuberosity (below knee), bottom of tibia (above ankle).

  • 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

Figure 4.31   

Inserting IO needle by hand

  • 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