Pediatric emergency medicine trisk 4342 4342

Equipment
Povidone-iodine or chlorhexidine antiseptic solution; sterile gauze; gloves;
drapes; 1% lidocaine; 3- to 5-mL syringe; 18- or 20-gauge intraosseous infusion
needle; or commercially available IO device (EZ-IO [Arrow/Teleflex] or bone
injection gun [Waismed/PerSys Medical]); saline flush solution; IV fluids and
tubing. Alternatives: bone marrow aspiration needle; 20-gauge lumbar puncture
(LP) spinal needle.

Procedure
Preferred locations are the proximal tibia or distal femur for ease of access and
safety. Prepare the selected site by cleansing with antiseptic solution. In the
awake patient, infiltrate from the skin to the periosteum with 1% lidocaine for
anesthesia. The desired site for placement in the proximal tibia is the flat, medial
surface 1 to 2 cm below the tibial tuberosity ( Fig. 130.9A ). Alternatively, the
lower third of the femur in the midline approximately 3 cm above the lateral
condyle ( Fig. 130.9B ) or the distal tibia 1 to 2 cm proximal to the medial
malleolus ( Fig. 130.9C ) can be used. In the absence of an intraosseous needle, a
bone marrow sampling needle or a spinal needle with bevel can be used.
After penetrating the skin with the needle, direct it at a slight angle 10 to 15
degrees from vertical and away from the growth plate of the long bone (caudad
for proximal tibia insertion; cephalad for distal femur insertion). Apply
downward pressure with a “to-and-fro” rotary motion to advance the needle.
When the needle passes through the cortex of the bone into the marrow cavity,
resistance will suddenly decrease (a “trap door effect”). The needle should stand
firmly without support. Remove the stylet and connect a 5-mL syringe to the
needle. Attempt to aspirate marrow to confirm placement of the needle tip in the
marrow space. If marrow cannot be aspirated, gently attempt to flush with saline
and assess for signs of infiltration. If the line can be flushed easily without signs
of infiltration, placement is good. Flush the needle with heparinized saline and
connect it to conventional IV infusion tubing. Observe the site for extravasation
of fluid, which is an indication that either the placement is too superficial or the

bone has been pierced through both sides. Restrain the leg and maintain a clean
infusion site while the needle is in place.
Use of the EZ-IO for placement involves the same preparatory steps to sterilize
the site. Use the 15-gauge, 15-mm needle for patients under 39 kg and the 15gauge, 25-mm needle for those over 39 kg. There is also a 15-gauge, 45-mm
needle available for use when excessive soft tissue overlies the desired insertion
site. Load the needle onto the magnetic tip of the drill. Insert the needle through