From the Guidelines
The recommended location for intraosseous line placement in a child with cardiopulmonary arrest when IV access cannot be obtained is the anteromedial surface of the proximal tibia. This is based on the most recent and highest quality evidence available, which prioritizes the proximal tibia as the preferred site for intraosseous access in children 1. The proximal tibia is preferred due to its accessibility and the lower risk of complications compared to other sites. Alternative sites, such as the distal tibia, may also be considered, but the proximal tibia remains the first choice. It is essential to direct the needle away from the growth plate in children, especially in infants under 12 months, to minimize the risk of growth plate injury. Intraosseous access should be established using an appropriate-sized IO needle or device based on the child's age and size, and proper placement should be confirmed by observing blood return, easy flush without extravasation, and the needle standing firmly without support. The use of intraosseous access is supported by recent guidelines, which suggest that it is an acceptable route of vascular access in infants and children with cardiac arrest 1. Additionally, intraosseous access has been shown to be a rapid, safe, and effective route for vascular access in children, and it is useful as the initial vascular access in cases of cardiac arrest 1. Overall, the anteromedial surface of the proximal tibia is the recommended location for intraosseous line placement in a child with cardiopulmonary arrest when IV access cannot be obtained.
Some key points to consider when establishing intraosseous access include:
- Using an appropriate-sized IO needle or device based on the child's age and size
- Directing the needle away from the growth plate in children, especially in infants under 12 months
- Confirming proper placement by observing blood return, easy flush without extravasation, and the needle standing firmly without support
- Establishing intraosseous access quickly, within 90 seconds, to minimize delays in delivering life-saving medications and fluids during cardiopulmonary arrest. Intraosseous access is preferred over endotracheal administration of medications, as it allows for more rapid and effective delivery of medications and fluids. Medications and fluids administered through an IO line have similar absorption rates to IV administration, making it an effective route during resuscitation. Overall, the use of intraosseous access in children with cardiopulmonary arrest is supported by recent evidence and guidelines, and it should be considered as a viable option when IV access cannot be obtained.
From the Research
Intraosseous Line Placement in Children
The recommended location for intraosseous line placement in a child with cardiopulmonary arrest where Emergency Medical Services (EMS) was unable to obtain intravenous (IV) access is:
Location Considerations
Considerations for the location of intraosseous line placement include:
- The proximal tibia is the preferred site for children under 5 years old, with insertion performed 1 to 3 cm below the tibial tuberosity on the flat anteromedial surface of the tibia 2
- The distal tibia or femur are preferred sites for children over 5 years old 2
- The anteromedial surface of the proximal tibia is recommended due to fewer critical structures being at risk and no compromise to blood flow to the lower limbs 3
Specific Placement Guidelines
Specific guidelines for placement include:
- Insertion at 10 mm inferior to the tibial tuberosity, where the smallest cortical thickness, largest medullary space, and largest anteromedial surface are observed 3
- Insertion at 0.5 cm below the tibial tuberosity in the midline of the medial surface, where the thinner part of the cortex and larger width of the medullar cavity are located 4