When is intraosseous (IO) access typically considered in patients, particularly in pediatric or critically ill individuals?

Intraosseous Access: When to Consider

Intraosseous (IO) access should be considered early in critically ill or injured children whenever peripheral venous access cannot be rapidly established, and it is recommended as the initial vascular access route in pediatric cardiac arrest. 1

Primary Indications for IO Access

Cardiac Arrest (Class I Recommendation)

• IO access is the preferred initial vascular access in pediatric cardiac arrest rather than attempting peripheral IV access 1
• All resuscitation medications can be administered via IO route with comparable onset and drug levels to IV administration 1
• The 2022 International Consensus reaffirms that IO should be considered early whenever venous access is not readily available in critically ill children 1

Failed or Difficult Peripheral IV Access

• Limit time spent attempting peripheral venous access in critically ill or injured children - if rapid peripheral access cannot be achieved, proceed to IO 1
• IO access can be established quickly with minimal complications by providers with varied training levels 1
• Studies show IO access is frequently more successful and achieved more rapidly than peripheral IV in children with shock 1

Clinical Scenarios for IO Consideration

Pediatric Emergencies

• Cardiac arrest (most common indication - 75.7% of cases) 2
• Multi-trauma with difficult access 2
• Hypovolemic shock 3
• Seizures/status epilepticus requiring immediate medication 2
• Respiratory failure requiring urgent intervention 2
• Severe burns with hypothermia 3
• Acute airway hemorrhage 3
• Laryngospasm requiring immediate treatment 3

Age Considerations

• IO is appropriate for all pediatric age groups, including infants and toddlers where venous access is particularly challenging 3, 4
• Nearly one-third of IO insertions occur in patients younger than 2 years 2

Practical Advantages

Speed and Reliability

• IO provides faster vascular access than central venous catheterization in emergencies 5
• Modern devices (EZ-IO) achieve 96% success rates compared to 50-55% with manual techniques 2
• First-attempt success rates are significantly higher with powered devices 2
• Average insertion time is 1-2 minutes 6

Medication Administration

• All IV medications can be given IO: epinephrine, adenosine, fluids, blood products, catecholamines, amiodarone, atropine, calcium, and others 1
• Use manual pressure or infusion pump for viscous drugs or rapid fluid boluses 1
• Always follow each medication with saline flush to promote entry into central circulation 1

Diagnostic Utility

• Blood samples can be obtained for type and cross-match, blood gases, and other analyses during CPR 1
• Caveat: Acid-base analysis is inaccurate after sodium bicarbonate administration via IO 1

Algorithm for Vascular Access in Pediatric Emergencies

1. Cardiac arrest: Proceed directly to IO access (Class I) 1
2. Critically ill child needing immediate access: Attempt peripheral IV only if achievable within 1-2 minutes; otherwise proceed to IO 1
3. Non-arrest but unstable: If peripheral IV fails after brief attempt, use IO rather than attempting central line 1
4. Central venous access: Not recommended as initial route during emergencies due to time requirements and technical demands 1

Important Caveats

Contraindications and Limitations

• Avoid IO in bones with fractures or previous IO attempts 4
• Flow rates are lower than large-bore peripheral IVs, but adequate with pressure bag systems 6
• Complications are rare but include extravasation (3.8%), insertion problems (19.2%), and technical failures (5.1%) 2
• No cases of osteomyelitis documented in follow-up studies 2

Comparison to Other Routes

• IO is superior to endotracheal drug administration - tracheal route requires 10 times the IV dose and produces less reliable effects 1
• Central venous access is time-consuming and not appropriate for initial emergency access 1
• Peripheral IV is acceptable if rapidly achievable, but should not delay care 1

Equipment and Training

• Modern powered devices (EZ-IO, Bone Injection Gun) have significantly higher success rates than manual needles 2
• All emergency services handling critically ill children should be familiar with IO techniques 2
• Immediate equipment access and clear departmental guidelines are essential 3