Question 8

List your indications and contraindications for the use of the lntraosseous needle. What are the risks associated with its use and how can they be minimised?

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College Answer

Lists were acceptable.

(a) Indications:
•  Venous access in collapsed. hypovolaemic or hypcrvolaemic child with DO other venous
access after several attempts
• Child up to 6 years of age
•  Administration of drugs or fluids

(b) Contraindications:
•  Age> 7years (relative contraindication. bone difficult to penetrate)
•  Other access available
•  No experience of technique

(c) Risks:
•  Osteomyelitis
•  Compartment syndrome from fluid extravasation
•  Bone marrow embolism

(d) Minimising risks:      .
•  Training and practice
•  Sterile technique
•  Establish conventional venous access ASAP and remove needle
•  Limb observation


This question is very similar to Question 15.1 from the first paper of 2012.

In the interest of revision, and because this question is worded slightly differently, the answer to Question 15.1 is modified and presented below.



  • Cardiac arrest
  • Need for immediate IV access, when it is difficult to establish by conventional methods


  • Underlying fracture
  • Underlying prosthesis
  • Severe osteoporosis
  • Contaminated site
  • Inability to identify landmarks
  • Insertion at a site of recently attempted IO access
  • Unfamiliarity with the device (you might hurt yourself)

Age is no longer a contraindication; IO access has become very popular in adults since this 2000 paper.


  • Osteomyelitis
  • Fracture
  • "through and through" penetration
  • Extravasation
  • Compartment syndrome due to extravasation
  • Injury to staff (slipped needle)
  • Damage to surrounding structures
  • Microscopic fat emboli

With sternal approach:

  • Mediastinal injury
  • pneumothorax
  • Greater vessel injury


Probably the best single reference for this:

Day, Michael W. "Intraosseous devices for intravascular access in adult trauma patients." Critical care nurse 31.2 (2011): 76-90.


Dev, Shelly P., et al. "Insertion of an Intraosseous Needle in Adults." New England Journal of Medicine 370.24 (2014).


James Cheung, Warren, Hans Rosenberg, and Christian Vaillancourt. "Barriers and Facilitators to Intraosseous Access in Adult Resuscitations When Peripheral Intravenous Access Is Not Achievable." Academic Emergency Medicine 21.3 (2014): 250-256.