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

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

Figure 4.19 Adult — spring loaded device proximal tibia insertion site

Figure 4.20 Child — proximal tibia insertion site

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 
  • 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   

  • 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   

Figure 4.23   

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

Figure 4.25   
  • 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   
  • 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   

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.

Figure 4.29   

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

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