8-21
What Not To Do:
Do not continue a transfusion when a patient complains of difficulty breathing and feeling bad during a
transfusion. Stop the transfusion, continue normal saline, and evaluate for possible transfusion reaction.
Do not reassure a patient that all transfusions are completely safe and without risk. There is always risk with
transfusion of blood products. Transfusion is preferred when the benefit of the transfusion, out weighs the
risk of the complications.
Procedure: Intraosseous Infusion
18D Manual Skills and Training Manual , Reviewed by LTC (Ret) John Zotter, VC, USAWhen: Intravenous access is unavailable or impossible to obtain. Infusion of fluids, blood or medications
into the tibia of a child or the sternum of an adult is the only route available (rare in adults since, central
venous access is usually possible).
What You Need: Alcohol swabs, intraosseous needles, an IV administration set, and IV solution.
What To Do:
- Intraosseous (IO) infusion should only be used on unconscious or gravely ill children under 6 years of age
when peripheral cannulation is unobtainable. - Apply gloves for personal and patient protection.
- Clean the site as for an IV infusion.
- NOTE: The site of choice for intraosseous infusion is the superior portion of the tibia, 1-2 finger widths
below the tibial tuberosity in children under age 6. The single recommended site of insertion for adults is
the manubrium (top 1/3 of the sternum), or on the midline and 1.5 cm (5/8 inch) below the sternal notch. - Select an intraosseous (bone marrow) needle or 16 or 18 ga. spinal needle.
- Put the child in a supine position. Use an uninjured lower leg and use padding to put the knee into
a 30° flexion. - Use a boring or screwing motion to advance the needle distally (away from the epiphysial plate) at a 45°
angle until it penetrates into the marrow. There should be a decrease in the resistance to advancement. - To check your needle placement, aspirate bone marrow into 10 cc syringe filled halfway with sterile saline.
It will not always be possible to aspirate marrow. - Cannot aspirate: Apply just enough pressure to plunger to clear needle tip of possible clot/bone particle,
then aspirate again. - Infuse 5-10ml of NS by syringe to ensure correct placement and to clear clots. Swelling around injection
site: indicates penetration of bone has not occurred and saline is being injected into fleshy tissue;
reassess and try again. - Secure the needle with tape if necessary.
- Attach an IV infusion set as with normal IV infusion.
- NOTE: Crystalloid solutions, blood, and most ALS drugs can be administered by this route.
- Recognize the contraindications to intraosseous infusion.
a. Fracture at or proximal to the infusion site.
b. Traumatized extremity.
c. Cellulitis at the infusion site.
d. Congenital bone disease. - Record all treatment in the patient’s medical record.
- FAST1 adult intraosseous infusion system is currently the only FDA kit approved for adults. Web site
for additional information http://www.pyng.com
What Not To Do:
Do not forget that medications can be delivered through this route at the same dose that would be given IV.
Do not use the sternal technique in small adults or children.