IO: A Procedure Review

IO: A Procedure Review

by Jacky Vaniotis, RN, NREMT-P

When is the last time you had to place an intraosseous needle into a child? It doesn’t happen very often, does it? Are you comfortable that you’d be able to do it if necessary, without hesitation? Do you remember what the indications are, or what equipment you must assemble as soon as you decide you need to do this procedure? Under what circumstances would responders not place an IO? What are some of the potential complications, and how can they be prevented? Let's take a few minutes and review this infrequently-used but critical procedure.

What are the indications for initiating intraosseous access? Well, first of all, the child must be six years old or younger, unresponsive, critically ill or injured, and in need of immediate vascular access. IO access should be attempted if you have spent 60-90 seconds attempting IV access, or if you have made three attempts without success.

An IO would not be placed into a bone which has had a recent fracture, if there had been prior infection at the insertion site, if there are burns overlying the site (unless there is no alternative), or if there have been attempts previously at the same site. IO access would not be indicated if the child is alert and stable.

Once you have established the need for intraosseous access, you must assemble your equipment. (This, of course, should be done long before the need arises. This way you’ll already have an IO kit together in your pedi bag, and won't be scrambling to gather the equipment in the middle of a critical situation.) Think of what you need by imagining your line from the patient to the infusion material. So, in this case, you would need, first of all, materials for skin preparation, either Betadine (povidone iodine) or alcohol. You'll need a small rolled towel to place under the child's leg. You will also need tape and possibly a rigid splint to secure the site once it's established, and something for a pressure dressing in case you are unsuccessful and need to remove the needle. You’ll need a couple of rolls of Kling. You’ll need the needle itself: most commonly used are 15 or 18 gauge Jamshidi-type needles. You'll need a 10-20 cc syringe with which to aspirate for marrow to confirm placement, and to flush. You’ll also need normal saline for flushing. Ideally you'll need some kind of short extension tubing, so as to avoid manipulating the needle directly. You'll need a three-way stopcock that will allow you to alternate between drawing up fluids and injecting them. (Some stopcocks have extension tubing already built in.) You'll need IV tubing and fluid—typically normal saline. (I prefer a 250 or 500 cc bag, so as to avoid the potential problem of losing track of how much fluid has been given, and thus minimizing the risk of causing circulatory overload). You'll also need a 60 cc luer-lock type syringe to be able to give boluses in measured amounts and under some pressure.

Once you have gathered all the equipment, the procedure is fairly straightforward. Assemble the tubing by spiking the administration set into the fluid bag, attaching the distal end of the administration set to the three-way stopcock, then to the extension tubing. Run the fluids through the tubing and hang the set within reach near the child. Fill the smaller of the two syringes with 10 mL saline flush. Select the insertion site, the anteromedial surface of the child’s tibia, 1-3 cm (1-2 fingers’ width) below and medial to the tibial tuberosity. Prepare the site with alcohol or povidone iodine starting at the center and working your way outward in ever-widening circles. Remove the protective covering from the needle, and assure that the bevels of the needle and the stylet line up. Insert the intraosseous needle at a 90 degree angle into the bone with a twisting or drilling (not rocking) motion. Insert in a direction slightly away from the bone’s growth plate. You should feel a distinctive pop as it passes through the hard bony exterior and into the softer marrow. Stop when you feel decreased resistance, to avoid pushing the needle all the way through to the posterior side of the bone. Remove the inner stylet and attach the syringe filled with saline flush. Withdraw to see if you get bone marrow, which will help confirm placement. You will not always get a marrow return, so flush a small amount of fluid (approximately 10 cc) and watch for signs of infiltration (tissue swelling around the site or on the posterior aspect of the child's leg).

Once you are sure you are in the marrow, screw the flange down so it is flat on the skin and secure it in place with tape. Further secure the needle with Kling and splint as necessary. Attach the pre-assembled and primed administration set to the IO needle. Attach the 60 cc syringe to the three-way stop cock, and turn the stop cock so that fluid is able to be pulled into the syringe. Close off the syringe and turn the stop cock so that fluid is now able to be administered to the patient. Repeat this process as often as necessary to give your total fluid bolus. (Remember, a fluid bolus for a child is 20 cc/kg. So, for example, for a two-year old who weighs approximately 30 pounds, you would be providing 272 cc fluid: 30 pounds is 13.6 kg, and 20 cc per 13.6 kg is a total of 272 cc.) Re-assess your patient after each fluid bolus, and re-administer as necessary.

No procedure is complete without documentation. You need to include on your run report form the fact that you started an IO, the time, the number of attempts, the site, the gauge and type of needle and the total amount and kind of fluid infused. It’s also not enough to just re-assess your patient; you also need to document your re-assessment findings.

Complications of IO are infrequent, but include tibial fracture, compartment syndrome, skin necrosis, and osteomyelitis. Other complications may include extravasation of fluids into the surrounding tissues or growth plate damage, both of which may occur if the needle wasn’t properly placed. Proper technique minimizes the risk of most complications.

Now that you have read this review, take a few minutes to go to your jump kit, confirm that you have all the supplies that you need, review the procedure, and make sure that your equipment all works together. There is nothing worse than finding out in an emergency, for example, that the IV tubing you are using is needle-less and all you have is a port that requires a needle, or that you don’t have a necessary piece of equipment to make the procedure work. Frequent review of infrequently-used but critical skills, such as IO insertion, can ensure that you’ll be able to do the skill when you need it, even if it’s your first time.

References

Mattera, Connie J., MS, RN. “Take Aim; Hit Your IO Target,” JEMS (April 2000); 38-48

American College of Emergency Physicians. Paramedic Field Care. St. Louis, MO: Mosby, 1997.

American Heart Association. Pediatric Advanced Life Support. 1997.

Bledsoe, Bryan E., Robert S. Porter, Bruce R. Shade. Paramedic Emergency Care. 3^rd ed. Upper Saddle River, NJ: Brady, 1997.