Intraosseous Access
In a small child in shock or cardiac arrest, a vein can be almost impossible to find. Intraosseous access — a needle into the bone marrow cavity — gives rapid vascular access, and it is a practical skill on the PALS course.
In short
Use IO when IV access cannot be obtained quickly in an emergency. Common site: the proximal tibia. Anything that can be given IV can be given IO, including drugs, fluids and blood. Watch for leakage into surrounding tissue.
In cardiac arrest and in severe shock when an IV cannot be placed rapidly. See cardiac arrest and shock.
The proximal tibia, on the flat surface just below and medial to the bony prominence below the knee, is the most commonly taught site in children. Other sites include the distal femur and distal tibia. Avoid fractured bones and sites of infection.
Manual or powered devices are used. Signs of correct placement include loss of resistance, the needle standing without support, the ability to aspirate marrow (not always possible) and a smooth flush without swelling.
Drugs, fluids and blood products. Fluid boluses may need pressure or a syringe push — see fluid resuscitation.
IO is a bridge; definitive access is obtained once the child is stabilised. It is practised on trainers in classroom PALS.
This guide summarises what the PALS course teaches, for education only. It is not a clinical protocol: follow the current American Heart Association guidelines, linked below, and your institution’s paediatric policies.
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When IV access cannot be obtained quickly in an emergency.
Most commonly the proximal tibia.
Drugs, fluids and blood that can be given IV can be given IO.
Leakage into the surrounding tissue; check the limb regularly.
Yes, on trainers.
Paediatric emergencies are learned by doing. Safety First Medical Services is an American Heart Association training centre on Al Reem Island, Abu Dhabi, with HeartCode, classroom and on-site PALS and a two-year AHA PALS Provider eCard.
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Last reviewed by the training team at Safety First Medical Services, an American Heart Association training centre at Addax Office Tower, Al Reem Island, Abu Dhabi. Call +971 55 761 9841 or email training@safetyfirstmed.ae.