Intraosseous Access

Updated: Apr 05, 2022
  • Author: Ee Tein Tay, MD; Chief Editor: Vincent Lopez Rowe, MD, FACS  more...
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Intraosseous vascular access is the placement of a specialized hollow-bore needle through the cortex of a bone and into the medullary space for infusion of medical therapeutic agents and laboratory testing. [1] It was first introduced by Drinker in 1922 as a method for accessing noncollapsible venous plexuses through the bone marrow cavity to the systemic circulation. With the development of intravenous (IV) catheters, this method was abandoned until the 1980s, when intraosseous access was reintroduced, particularly for rapid fluid infusion during resuscitation. [2]

On the basis of previous guidelines, intraosseous access was suggested for children aged 6 years or younger, [3]  though subsequent studies showed that it is safe in older children and adults. [4, 5, 6, 7]  Successful infusions in newborns further suggested that access via the intraosseous route is faster than access via umbilical veins. [8, 9]

The Emergency Cardiovascular Care Guidelines of 2000 recommended intraosseous access in all children after two failed attempts at IV access or during circulatory collapse. In 2010, the American Heart Association (AHA) recommended intraosseous access if IV access cannot be quickly and reliably established. [10]  This position was largely retained in subsequent updates to the AHA guidelines. [11, 12, 13]

Intraosseous access may be easily established by users with little training and is more rapidly achieved than IV access. [14]  Manual insertion with force had previously been the primary method for intraosseous insertion, but automated intraosseous insertion devices such as the Arrow EZ-IO (Teleflex, Morrisville, NC) [15]  have been growing in popularity. [16]  Studies suggested that these automated devices are safe and highly successful on first attempts in both children and adults. [17, 18, 19, 20]

Several articles have described the use of intraosseous access in military and rescue scenarios, where rapid access may be crucial, peripheral venous access may be hard to obtain, and first responders may have limited experience or technical capacity. [21, 22, 23, 24, 25]

Blood obtained through intraosseous access may be used to obtain most laboratory values, including pH level, carbon dioxide tension (PCO2), and ABO and Rh typing. [26]  The results of these standard laboratory tests may differ slightly from results obtained with venous blood samples because of low flow and stasis in the bone marrow. More study is needed on the comparability of values from intraosseous samples and those from arterial or venous samples. [27]

All medications and blood products can be safely administered through the intraosseous line, and the onset of action and peak drug levels are comparable to those of IV administration.

Intraosseous access has also been employed for injection of contrast media in computed tomography (CT) angiography (CTA). [28]

Intraosseous needles left in the marrow for longer than 72 hours are at a higher risk of local infection; thus, needles should be removed as soon as permanent venous access is established.



One indication for intraosseous access is difficulty in establishing venous access, as in the following settings:

  • Burns
  • Obesity
  • Edema
  • Seizures

Another is a condition necessitating rapid high-volume fluid infusion, such as the following:

  • Hypovolemic shock
  • Burns

Another is to afford access to the systemic venous circulation, as with the following:

  • Cardiopulmonary arrest [29, 30, 31]
  • Burns
  • Blood draws
  • Local anesthesia
  • Medication infusion

Intraosseous administration of 23.4% sodium chloride solution for the treatment of neurologic emergencies has been described. [32, 33]



Contraindications for intraosseous access include the following:

  • Infection at the entry site
  • Burn at the entry site
  • Ipsilateral fracture of the extremity
  • Osteogenesis imperfecta
  • Osteopenia
  • Osteopetrosis
  • Previous attempt at the same site
  • Previous attempt in a different location on the same bone
  • Previous sternotomy (sternum insertion)
  • Sternum fracture or vascular injury near the sternum (sternum insertion)
  • Inability to locate landmarks - There is some evidence to suggest that point-of-care ultrasonography may prove useful for identifying proximal humerus landmarks for intraosseous access [34]