Intraosseous access

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An intraosseous access or an intraosseous infusion is a form of application in which infusions or drugs are administered intraosseously (into the bone marrow cavity). During the intraosseous puncture required for this , a steel cannula is inserted into the bone , through which the substances can be administered due to the good blood flow in the bone marrow cavity.

Use of intraosseous access often in children emergencies and small domestic and pet animals , as it is sometimes difficult for these, the small veins with an IV catheter to puncture. In principle, however, it can be used in all age groups and is also increasingly used by adults. The intraosseous access is a comparable alternative to venous catheters for the infusion of fluids, the application of medication and blood collection. In an emergency, all common medications and blood products can be applied, and blood can also be taken. The advantages of intraosseous puncture are its rapid application and high success rates (> 80%) with a low risk of complications. Disadvantages are the higher costs for material and a limited flow rate of the puncture needles in some systems.

Intraosseous injection was already being used successfully in the 1940s.


The use of an intraosseous access is an important alternative if venous access via an indwelling venous cannula is not possible due to difficult environmental conditions or patient-specific aspects ( obesity , vascular damage, difficult puncture in children) . In the guidelines of the American ( AHA ) and European resuscitation committees ( ERC ), intraosseous access is recommended as an alternative to peripheral venous access in the context of cardiopulmonary resuscitation ; endobronchial application is no longer recommended according to ERC Guidelines 2010 ( endobronchial ) . In military and emergency medicine, the technique is used to create access points on unsteady platforms, for example on rubber dinghies or in vehicles during off-road driving, even during supply, since puncturing the vein is difficult due to the vibrations.

Before inserting the needle, the puncture site should be disinfected if possible. When patients are awake, local anesthesia of the skin and bone surface should be used to relieve the pain when drilling or puncturing, if there is enough time for these preparatory measures in an emergency. After the needle has been inserted into the bone marrow cavity, a small dose of a local anesthetic (e.g. lidocaine 2%) should be injected into the conscious patient to relieve the pain when injecting the other medication. The correct position of the needle tip in the bone marrow space can be checked by sucking in bright red streaky flowing bone marrow. The needle often has to be flushed with saline under pressure before the bone marrow can be aspirated. However, in around 20% of cases, no bone marrow can be sucked in despite the correct position of the needle. Signs of a correct position are then a stable, not wobbling needle and normal dripping of the connected infusion after a single pressure flushing of the needle. Signs of a misalignment of the needle are a wobbling needle, insurmountable resistance during the injection and fluid accumulation under the skin at the puncture site.


An intraosseous access is relatively contraindicated in the presence of osteogenesis imperfecta (glass bone disease), local foci of infection, bone fractures and pre-punctures on the affected bone.

Puncture sites

The preferred puncture site is the upper part of the tibia (proximal tibia) on the inside, about two centimeters below the tibial tuberosity . In addition, the stand as alternatives among other thigh bone ( femur ), the upper arm bone ( humerus ) and the Spina illiaca anterior superior of the ilium available. Puncture of the breastbone ( sternum ) is also possible. However, it is rarely used because of the potentially life-threatening complications and the disruptive influence on resuscitation measures (chest compressions, etc.).


Overall, complications are rare. If the cannula is incorrectly positioned, a compartment syndrome can occur. If excessive force is used, a fracture of the tibia can result. Inflammation ( osteomyelitis ) and embolism are rare if the patient is kept there for a short time, as well as injuries to the epiphyseal plate with consequent growth disorders . An unpleasant side effect can be pain when injecting medication into the bone marrow cavity. Therefore, a local anesthetic should be given with the first injection in awake patients.


Various systems are available commercially. The use of various products was examined in a study with 30 US soldiers. After brief instruction of the soldiers, the products were used on corpses. The products BIG, FAST, Cook needle and Jamshidi needle were compared, with the experiment showing no significant differences in terms of application safety and speed.

Cook and Jamshidi needles

Cook or Jamshidi needles have a point grind suitable for drilling and a large handle at the end of the needle and allow the needles to be inserted manually. These needles are inserted manually into the bone and are designed for different puncture sites.


The FAST1 system from the US company PYNG Medical is designed for puncturing the sternum (sternum) in people over the age of 12, but is mainly used in the military sector. FAST stands for First Access for Shock and Trauma. In the event of injuries in a military environment, B. arms and legs injured by explosions, so that they are not available for intraosseous access. On the other hand, the sternum is often uninjured by wearing bulletproof vests or splinter vests and offers itself as an intraosseous access point. In the Bundeswehr, the FAST1 model is made available to paramedics and trained infantrymen. The puncture location in the upper area of ​​the sternum is marked by a specially shaped adhesive plaster plate. Several stabilizing needles penetrate the skin until they make contact with the bone. When all of the stabilizing needles are in contact and have even pressure on the bone surface, a lock is released and the entire handle slides a few millimeters towards the sternum, inserting the main needle in the middle. When the handle is withdrawn, only the main needle remains in the breastbone and the handle and the stabilization needles are also removed. The adhesive plasterboard remains in place and, with a dome-shaped viewing window to be glued on, serves as protection for the puncture site and holder for the connected plastic tube.


The EZ-IO system from the US company Vidacare provides access using a battery-powered drill in which the infusion needle is drilled in directly in one step. Different needles are available:

  • Child 3–39 kg body weight with 15 mm maximum drilling depth, color pink
  • Patients from 3 kg with a maximum drilling depth of 25 mm, color blue
  • Adults overweight from 40 kg or proximal humerus with a maximum drilling depth of 45 mm, color yellow

After drilling, the internal drill cutting insert is removed and the outer infusion cannula remains, to which a plastic tube is connected. The EZ-IO is used in the German rescue service. The disadvantage of the EZ-IO system is that it contains a sealed lithium battery that cannot be replaced. Thus, only 500 punctures are possible with the device. The device must then be replaced.

Bone Injection Gun

With the Bone Injection Gun (BIG) from the US company Waismed, the cannula is shot into the bone marrow with a spring mechanism (see nail gun ). The penetration depth can be adjusted within certain limits using a screwable spacer.

  • Children up to 12 years with a maximum penetration depth of 1.5 cm, color red (18 gauge )
  • Adults from 12 years with a maximum penetration depth of 2.5 cm, color blue (15 gauge)

Individual evidence

  1. a b L. Aniset, J. Meinhardt, H. Genzwürker: The intraosseous approach. An important alternative in an emergency. In: Anasthesiol Intensivmed Emergency Med Schmerzther. 42 (7), Jul 2007, pp. 494-499. PMID 17661258
  2. LM Tocantins, JF O'Neill, HW Jones: Infusions of blood and other fluids via the bone marrow. In: JAMA . 117, 1941, pp. 1229-1234.
  3. JP Nolan, J. Soar, DA Zideman, D. Biarent, LL Bossaert, C. Deakin, RW Koster, J. Wyllie, B. Böttiger: Abstract: Section 1 of the guidelines for resuscitation 2010 of the European Resuscitation Council. ( Memento of the original from July 25, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. On behalf of the ERC Guidelines Writing Group @1@ 2Template: Webachiv / IABot /
  4. a b c Vidacare EZ IO Directions for use 2008, German supplement to the English Directions for use
  5. C. Eich, M. Weiss, D. Neuhaus, M. Sasse, K. Becke, J. Strauss: The intraosseous infusion in pediatric emergency medicine and pediatric anesthesia. In: Anästh Intensivmed. 51, 2010, pp. 75-81.
  6. a b E.-M. Jordi Ritz, TO Erb, FJ Frei: Vascular Access in Pediatric Emergency Anesthesia. In: Anaesthesiologist. 54, 2005, pp. 8-16. PMID 15609024
  7. ^ JG Fortner, ES Moss: Death following sternal puncture: report of two cases. In: Ann Intern Med . 34, 1951, pp. 809-815. PMID 14811303
  8. ^ RT Fiser, WM Walker, JJ Seibert, R. McCarthy, DH Fiser: Tibial length following intraosseous infusion: a prospective, radiographic analysis. In: Pediatr Emerg Care. 13, 1987, pp. 186-188. PMID 9220503
  9. ^ MD Calkins, G. Fitzgerald, TB Bentley, D. Burris: Intraosseous infusion devices: a comparison for potential use in special operations. In: The Journal of Trauma . 6, 2000, pp. 1068-1074. PMID 10866253
  11. accessed on December 25, 2018.
  12. Waismed

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