1. Emergency IV access when other venous access is not
readily available; to restore intravascular volume so that
peripheral venous access becomes possible. See Table
50.1 for categories of fluid and medications that have
1. Bone without cortical integrity (fracture, previous penetration): Extravasation of infusate
2. Sternal site: Potential damage to heart and lungs (7)
3. Overlying soft tissue infection
5. Obliterative diseases of marrow such as osteopetrosis
5. 1% lidocaine in 1-mL syringe with a 25-gauge needle
6. Needle, in order of preference (1–3,10)
a. Bone marrow or intraosseous needle (18-gauge)
(stylet and adjustable depth indicator preferred)
b. Short spinal needle with stylet (18- or 20-gauge)
c. Short hypodermic needle (18- or 20-gauge)
d. Butterfly needle (16- to 19-gauge) (8)
7. 5-mL syringe on a three-way stopcock and IV extension
8. IV-infusion set and IV fluid
9. 5-mL syringes with saline flush solution
Intraosseous needle placement device (intended for use at
the proximal tibial location). Devices approved for newborns
are the battery operated driver EZ-IO PD (Pediatric) (Vidacare,
San Antonio, Texas) (approved for 3 kg or larger), and the
spring-activated B.I.G. Bone Injection Gun (WaisMed,
Houston, Texas). There are company-provided reports of use
with manual insertion of the intraosseous needle (9).
1. Small sand bag or rolled towel to aid in stabilizing limb
2. Avoid inserting needle through infected skin or subcutaneous tissue.
3. Stabilize limb with counterpressure, with sand bag or
towel roll directly opposite proposed site of penetration,
4. If hand is also used to stabilize limb, do not position
goes through the limb. This is true regardless of whether
a sand bag or towel is used. Limit needle size to decrease
marrow damage, dilute hypertonic or strongly alkaline
solutions prior to infusion (2).
6. Discontinue intraosseous infusion as soon as alternative
venous access is established, to reduce risk of osteomyelitis.
Proximal Tibia (1–3,12) (Fig. 50.2)
2. Place sand bag or towel roll behind knee to provide
countersupport behind puncture site.
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