Back to Basics: Intraosseous Lines

Back to Basics: Intraosseous Lines

Author: Rahul Gupta, MD



       Failure to gain IV access in critical patient (burns, shock, resuscitation)

       Temporizing measure to allow stabilization and to facilitate long-term IV access


       Fractured at or proximal to site or previously penetrated

       Vascular interruption

       cellulitis overlying skin

       Bone disease (OI, osteoporosis)


       Long-term use - >24 hours associated with osteomyelitis

       Fracture, extravasation, compartment syndrome

       Insertion Site:

       Proximal tibia (2 finger widths below tibial tuberosity)

       Distal femur

       Distal tibia/fibula

       Proximal humerus - arguably the best due to highest flow rate, but may interfere with resuscitations activities

       Sternum - best if all limbs are injured

       Anterior superior iliac spine: best in soft boned pediatric patients


       15 mm - pink (3-39kg person), 25 mm - blue (>40kg person), 45 mm - yellow (>40kg with lots of subcutaneous tissue)

       Yellow is the color of fat

       Pink is exclusively Peds

       Confirmation of Line

       Achieved with aspiration of bone marrow, flushing needle without evidence of extravasation, and clear visualization of needle standing firmly in bone

       Fluid Infusion

       Can infuse IV drug or fluid (same dose); flush with 20 mL saline flush

       Rate: sternum > proximal humerus > tibia


       Accurate: Hgb/Hct, pH, pCO2, Bicarb, chloride, BUN, creatinine, glucose, serum drug levels, cultures, albumin

       Inaccurate: WBC, Potassium, Ionized Ca, AST/ALT, Blood oxygenation




1. Moore GP, Pace SA, Busby W. Comparison of intraosseous, intramuscular, and intravenous administration of succinylcholine. Pediatric Emergency Care. 1989;5(4):209–210.

2. Mittiga MR, Ruddy RM. Procedures. In: Shaw KN, Bachur RG, eds. Fleisher & Ludwigs Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia, PA: Wolters Kluwer; 2016:(Ch) 141.

3. Bloch SA, Bloch AJ, Silva P. Adult intraosseous use in academic emergency departments and simulated comparisons of emergency vascular access techniques. Annals of Emergency Medicine. 2010;56(3):S152.

4. Leidel, B.A., Kirchhoff, C., Bogner, V., Stegmaier, J., Mutschler, W., Kanz, KG., & Braunstein, V. (2009). Is the intraosseous route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery, 3(1), 24-31. doi: 10.1186/1754-9493-3-24