Intraosseous Puncture
(proximal tibial route)

Procedure is for
- children <7
- where venous access is impossible
- or IV attempts failed x2
- discontinue as soon as venous access obtained

1. Place pt supine.  Pad under uninjured knee to 30o of flexion while heel rests comfortably.

2. Identify puncture site: anteriomedial surface of proximal tibia, 1 finger below the tubercle.

3. Cleans skin well, drape area, wear sterile gloves.

4. Use local anaesthetic into puncture site if awake.

5. Introduce large calibre bone-marrow aspiration needle at 90o to skin and periosteum with bevel toward foot (away from epiphyseal plate)

6. After gaining purchase on bone, direct needle 45o to 60o away from epiphyseal plate.  Use twisting/boring motion to advance needle through bone cortex and into marrow.

7. Remove stylet and attach needle to 10ml syringe filled with 6ml sterile saline.  Withdraw on plunger.  Aspiration of marrow into syringe signifies entry.

8. Inject saline to expel clot. If no swelling seen, placed appropriately, even if marrow was not aspirated.  Needle should also remain upright without support and IV solution flowing freely through it.

9. Apply antibiotic ointment and 3x3 sterile dressing.  Secure needle and tubing.

10. Routinely reevaluate placement, limit infusinoon to emergency resuscitation.

Through penetration of bone
Subcutaneous infiltration
Pressure necrosis of skin
Physeal plate injury