Question 15
a) Identify this piece of equipment.
b) What are the physiological principles underlying its use in the shocked patient?
c) List four sites where it may be used.
d) How would you confirm appropriate placement?
e) List four complications of its use.
f) What are the contraindications to its use?
College Answer
a)
Intraosseous needle (with insertion driver).
b)
The marrow of long bones has a rich network of vessels that drain into a central venous canal,
emissary veins, and, ultimately, the central circulation. Therefore, the bone marrow functions as a
non-collapsible venous access route when peripheral veins may have collapsed because of
vasoconstriction. This approach is particularly important in patients in shock or cardiac arrest, when
blood is shunted to the core due to compensatory peripheral vasoconstriction. The intraosseous
route allows medications and fluids to enter the central circulation within seconds.
c)
- Proximal tibia
- Femur
- Distal tibia (medial malleolus)
- Proximal humerus
- Manubrium (upper sternum)
The anterior inferior iliac spine, clavicle, and distal radius have also been used successfully for IO
vascular access as have bones without medullary cavities, including the calcaneous and radial
styloid
d)
- Aspiration of bone marrow
- Ability to flush fluid with no evidence of extravasation
e)
- Extravasation of fluid/Compartment syndrome
- Infection/Osteomyelitis/Bacteraemia
- Fracture
- Haematoma
- Growth plate injury (in children)
- Fat embolus
f)
- Proximal ipsilateral fracture
- Ipsilateral vascular injury
- Local cellulitis/infection
- Inability to locate landmarks
- Osteogenesis imperfecta
Discussion
This question is very similar to Question 15.1 from the first paper of 2012, and to Question 8 from the first paper of 2000. The only difference in this version is the addition of the "how would you confirm placement" bit. In brief:
Your IO is in the right place if
- You are able to aspirate bone marrow (which looks a lot like venous blood)
- You are able to flush the line with little resistance, and with no obvious extravasation
Additional methods to confirm placement:
- Ultrasound- colour flow within the intraosseous space (though this is so far experimental)
- Circumferential pressure around to the IO site: if the needle is extravasating into soft tissues, the gravity-fed fluid infusion rate will slow considerably when those soft tissues are compressed by a blood pressure cuff.
- X-rays
References
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.
Luck, Raemma P., Christopher Haines, and Colette C. Mull. "Intraosseous access." The Journal of emergency medicine 39.4 (2010): 468-475.
Stone, Michael B., Nathan A. Teismann, and Ralph Wang. "Ultrasonographic confirmation of intraosseous needle placement in an adult unembalmed cadaver model." Annals of emergency medicine 49.4 (2007): 515-519.
STRAUSBAUGH, STEVEN D., et al. "Circumferential pressure as a rapid method to assess intraosseous needle placement." Pediatric emergency care11.5 (1995): 274-276.