Intraosseous access

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Site and Anatomy

Proximal tibia (anteromedial surface)
Adult: two fingerbreadths below and medial to the tibial tuberosity.
Child: one fingerbreadth below tibial tuberosity (or two fingerbreadths below patella) and then medial on the flat aspect of the tibia.

Distal tibia (medial surface)
Adult: two fingerbreadths proximal to the tip of the medial malleolus.
Child: one fingerbreadth proximal to the tip of the medial malleolus.

Distal femur (anterolateral surface)
3 cm above lateral femoral condyle (child).

Pelvis (iliac crest)
Palpate the anterior superior iliac spine (ASIS); continue posterolaterally along the iliac crest to the insertion point 5–6 cm from the ASIS (adult).

Humerus (greater tubercle)
1.Palpate the anterior midshaft humerus. Continue palpating
proximally up the anterior surface of the humerus until the greater tubercle is met.
2.Palpate coracoid and acromion. Imagine a line between them and drop a line approx 2 cm from its midpoint to the insertion site (adult/older child)

Sternum (manubrium)
One fingerbreadth (1.5 cm) below the sternal notch in the midline (adult). Sternal devices only.


  • Emergency Situations where peripheral intravenous access may be difficult or has failed.
  • Gaining emergency access to the circulatory system in the pediatric patient


  • Proximal ipsilateral fracture
  • Previous IO attempts in the same bone
  • Previous surgery at insertion site (e.g. sternotomy/knee replacement)
  • Osteogenesis imperfecta (relative)
  • Osteoporosis (relative)
  • Overlying infection (relative)
  • Inability to identify landmarks (e.g. obesity)


Aspirate Tests

Marrow sample aspirate can be used for acid–base status, glucose, electrolytes, haemoglobin, cross-match testing.


  • Extravasation
  • Compartment syndrome
  • Osteomyelitis (0.6%)
  • Fracture
  • Fat embolism (rare)
  • Growth plate injury (theoretical)


Pain on initial infusion is due to intraosseous vessel wall distension and may be severe. It can be reduced in the conscious patient by the administration of 20–40 mg lidocaine (0.5 mg/kg pediatric) through the device before commencing an infusion.

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