PALS Provider: Course
Intraosseous (IO) Access in Children
Intraosseous (IO) access is a lifesaving alternative when peripheral IV access fails, especially in critically ill or arresting pediatric patients. It provides rapid vascular access by delivering fluids and medications directly into the bone marrow, which acts as a non-collapsible venous network.
Why Is IO Access Important?
- Fast and reliable alternative to IV in emergencies.
- Allows immediate fluid resuscitation and medication administration.
- Recommended by PALS/ACLS when IV access is difficult or delayed.
Indications for IO Access
- Failure to obtain IV access after multiple attempts.
- Cardiac arrest or life-threatening shock.
- Severe dehydration requiring immediate fluid resuscitation.
- Status epilepticus requiring urgent IV medication.
- Sepsis, trauma, or burns where venous access is challenging.
Contraindications: Fracture or significant injury to the targeted bone, previous IO attempt in the same bone, infection or cellulitis over the insertion site, osteogenesis imperfecta.
Common IO Access Sites in Children
| Site | Best For | Landmarks |
|---|---|---|
| Proximal Tibia | All ages | 1–2 cm below tibial tuberosity, medial to tibial shaft |
| Distal Femur | Infants & small children | Midline, 1–2 cm above patella, perpendicular to femur |
| Proximal Humerus | Older children & adolescents | Greater tubercle, lateral to bicipital groove |
Technique for IO Insertion
- Equipment: IO needle, powered/manual driver, flush, extension set, antiseptic, lidocaine (if conscious).
- Position and Prepare: Supine position, landmark identification, antiseptic prep.
- Insert the IO Needle: 90° angle with drill or manual device until sudden drop in resistance.
- Confirm Placement: Aspirate marrow (if possible), flush with saline, confirm no swelling or resistance.
- Secure the Line: Use a stabilizer, document time, remove IO within 24 hours.
Note: If flush does not flow easily, suspect malposition and replace IO immediately.
Complications & Troubleshooting
| Complication | Cause | Solution |
|---|---|---|
| Extravasation | Malposition or limb movement | Remove IO, apply pressure, use new site |
| Infection (Osteomyelitis) | Prolonged placement | Remove IO and monitor if infection suspected |
| Pain with Infusion | Conscious patient without lidocaine | Administer intraosseous lidocaine |
| Fracture | Excessive force or poor technique | Select alternate site and reassess technique |
Medications and Fluids Through IO Access
IO access can deliver any medication or fluid typically given via IV, with absorption comparable to central venous access.
- Fluids: Normal saline, LR, dextrose (D10, D25, D50), blood products.
- Medications: Epinephrine, atropine, adenosine, amiodarone, sodium bicarbonate, antibiotics.
Flush all medications with 5–10 mL of normal saline.
Comparison: IV vs. IO Access in Pediatric Emergencies
| Feature | Peripheral IV | Intraosseous (IO) |
|---|---|---|
| Speed of Placement | Slower, especially in shock | Faster (30–60 seconds) |
| Reliability | Veins may collapse | Consistent, non-collapsible |
| Usability | First-line option | When IV access fails |
| Medication/Fluid Compatibility | All IV-compatible agents | Same as IV |
| Complications | Infiltration, phlebitis | Extravasation, osteomyelitis, fracture |
Summary: Why IO Access Is a Critical Resuscitation Skill
- IO access is the fastest, most reliable backup when IV fails.
- Proximal tibia is most commonly used; humerus may offer faster delivery in older children.
- All emergency medications and fluids can be given IO.
- Remove IO lines within 24 hours to reduce infection risk.
Takeaway: In life-threatening pediatric emergencies, IO access can be the difference between life and death. Mastering this technique ensures rapid intervention when time is critical.