CME Review Article

Intraosseous Infusion
A Review of Methods and Novel Devices
Stephen M. Blumberg, MD, Michael Gorn, MD, and Ellen F. Crain, MD, PhD

intraosseous (IO) infusion has proven to be lifesaving in

Abstract: This is a review article of intraosseous infusion methods
and devices. severely ill children and is now regaining popularity in adult
medicine. The purpose of this article is to review the history,
Key Words: intraosseous infusion, pediatric resuscitation, fluid, methods, devices, implementation, and recommendations
drug therapy related to IO infusion therapy.
Dr C.K. Drinker, in 1922, is credited with the first
TARGET AUDIENCE experiments in mammals proving that the bone marrow
This CME activity is intended for physicians, nurse could represent a Bnoncollapsable vein.[1 The first report of
practitioners, nurses, and paramedics who manage children successful intramedullary infusion of blood, fluids, and
and adolescents in an emergency department, prehospital various medications in 14 human subjects was published in
setting, intensive care unit, or general hospital floor. 1940 by Drs Tocantins and O_Neill of Philadelphia.2
Specialists including pediatricians, emergency physicians, Research on drug pharmacokinetics and laboratory data
pediatric emergency physicians, surgeons, and anesthesiolo- related to infusion rates after IO infusion was also initiated
gists will find this information especially useful. at that time.3,4 The IO technique gained popularity and was
widely implemented during World War II by battlefield
LEARNING OBJECTIVES medics to save the lives of wounded soldiers. Unfortunately,
After completion of this article, the reader will be this experience did not translate into civilian use during the
able to: postwar era. Despite the birth of Emergency Medical
1. Explain the indications and contraindications for intra- Services (EMS) and large trauma centers in the late 1960s,
osseous needles. the art of IO was largely forgotten because of the advent and
2. Explain the anatomical considerations that influence the widespread introduction of plastic IV catheters. However,
placement of an intraosseous needle. the IO technique continued to be used in the military and in
3. Describe the methods and devices for placing intra- third-world countries.5
osseous needles, along with their advantages and dis- In 1981, the American Heart Association (AHA) and
advantages. the American Academy of Pediatrics added a section on
Pediatric and Neonatal Resuscitation to the Advanced

O btaining vascular access is often challenging in patients

with severe burns or in states of shock. Although
intravenous (IV) cannulation remains the primary route of
Cardiac Life Support (ACLS) curriculum. In addition,
1981 witnessed the development of the BPALS for Life[
curriculum at the Medical College of Wisconsin. This new
delivering parenteral therapy under routine circumstances, course became a part of a required pediatric care curriculum
for pediatric housestaff, and has grown into the AHA
Assistant Professor of Pediatrics (Blumberg), Fellow of Pediatric Emer-
Pediatric Advanced Life Support (PALS) course.6 Interest-
gency Medicine (Gorn), Professor of Pediatrics and Emergency ingly, the IO technique remained mostly unknown and was
Medicine (Crain), Division of Emergency Medicine, Department of not included in the initial ACLS or PALS curricula. The
Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, year 1984 witnessed a rediscovery of the IO in mainstream
Bronx, NY. medicine. Robert Berg7 published a report on successful
The authors have disclosed that they have no significant relationship with or
financial interests in any commercial companies that pertain to this continuous catecholamine infusion via IO in a 6-month-old
educational activity. infant with arthrogryposis. Dr James Orlowski,8 who had
All staff in a position to control the content of this CME activity have witnessed the lifesaving potential of IO in cholera patients
disclosed that they have no financial relationships with, or financial during a trip to India, wrote an editorial that accompa-
interests in, any commercial companies pertaining to this educational
activity.
nied Berg_s report advocating the use of IO in pediatric
Lippincott CME Institute, Inc. has identified and resolved all faculty and patients. Finally, later in the 1980s, IO became part of the
staff conflicts of interest regarding this educational activity. PALS guidelines and became standard of care during the
Address correspondence and reprint requests to Stephen M. Blumberg, MD, resuscitation of sick infants and children younger than 6
Division of Pediatric Emergency Medicine, Jacobi Medical Center, 1400 years. The most recent addition of PALS guidelines states
Pelham Parkway South, Bldg No. 6, Room 1B-25, Bronx, NY 10461.
E-mail: sblumberg11@yahoo.com. that IO should be used in pediatric patients of any age. In
Copyright * 2008 by Lippincott Williams & Wilkins 2005, the AHA revised its ACLS guidelines to include
ISSN: 0749-5161/08/2401-0050 recommending IO access in critically ill adults as well, when

50 Pediatric Emergency Care  Volume 24, Number 1, January 2008

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Pediatric Emergency Care  Volume 24, Number 1, January 2008 A Review of Intraosseous Infusion Methods and Devices

IV access is not available. In fact, the AHA now recom- action and pharmacokinetics of drugs administered via the
mends IO as the first alternative to IV in adult cardiac arrest IO route is equivalent to that of central and peripheral
patients and has given this recommendation Class IIa venous lines.23Y34 When compared with central line insertion
status.9Y11 and infusion, the IO technique may be both safer and faster,
ANATOMY AND PHYSIOLOGY and when compared with endotracheal administration of
The principle of IO infusion is based on the inherent medications, IO has faster onset of action and more
vascularity of bone. The IO space is connected to the central predictable bioavailability.35
circulation through a system of noncollapsible bony sinu- Early laboratory testing of electrolytes and blood
soids and vessels. The diaphysis or shaft is composed of counts may be critical in emergency situations. Investigators
hard compact bone that encloses the medullary cavity. As have compared the results of laboratory tests obtained from
the compact bone reaches toward the epiphyses, it widens venous sampling with the simultaneous results obtained
in diameter and thins. The epiphysis is composed of through bone marrow aspiration.36Y41 Based upon studies of
cancellous bone that is spongelike. All sections of the long anesthetized dogs and pigs, as well as of children with
bones contain marrow. Red marrow exists in cancellous leukemia undergoing bone marrow biopsy, there is a good
bone during infancy and childhood, and is highly vascular. degree of correlation between serum and marrow electro-
Over time, it becomes infiltrated by fatty tissue. The in- lytes, hemoglobin, drug levels, blood group typing, and tests
numerable vessels and sinusoids of the IO space are con- of renal function, and less correlation between PCO2, PO2,
nected to the central circulation by longitudinal Haversian and liver function tests.36Y41 However, a recent study in a
canals and the penetrating cross-connecting Volkmann dog model simulating low flow physiological conditions
canals. The term IO space refers to both the cancellous suggested that bone marrow values are less correlated to
bone of the epiphysis and the medullary cavity of the diaph- serum values after 30 minutes of cardiopulmonary resusci-
ysis that are connected.12 There are both somatic pain tation and/or drug and fluid administration.41 It would be
sensors within the skin and periosteum of bone and visceral safe to conclude that marrow samples obtained at the time of
pain sensors within the IO space.12,13 placement of the IO needle may be useful in making clinical
The original studies involving adult patients used the decisions in a critical patient.36Y41
sternal manubrium. This site was initially used because the Contraindications to IO needle use are few and for the
sternum is relatively thin, it contains well-vascularized most part are intuitive. The only strict contraindication is
marrow, and the landmarks are easily accessible and placing an IO line into a bone that has been fractured.
identifiable.2,3 The unique anatomy of the long bones has Intraosseous line placement should be avoided through dirty
resulted in the use of multiple sites for IO needle placement or infected skin, or in patients with bone disorders such as
in children. The proximal tibia, distal femur, distal radius, osteopetrosis or osteogenesis imperfecta. Finally, IO place-
medial malleolus, anterior iliac spine, and the clavicle have ment should not be attempted twice in the same bone
been successfully used for IO vascular access. Recent because there is concern that fluids can extravasate through
cadaveric studies have demonstrated that bones without the initial IO puncture site.
medullary cavities, such as the calcaneus and radial styloid, Intraosseous needle insertion is considered to be
may also be used for IO infusion.14,15 relatively safe and easy to perform in the hands of a skilled
The proximal tibia has long been used as the primary provider. The overall rate of significant morbidity has been
site of IO infusion in pediatric patients because of its large estimated to be less than 1% for all occurrences combined.24
marrow space, large flat portion just below and medial to the Extravasation of fluid and superficial skin infections are the
inferior border of the patella, and easily identifiable land- most common adverse effects. Skin necrosis, bone fractures,
marks. However, as children age, the cortex becomes osteomyelitis, and compartment syndrome are much less
significantly harder. Often, manual IO needles cannot be commonly reported.39Y43 Although there are no clinical
placed easily in the tibia of older children and adults. The reports to date, the potential for significant bone growth
only bone in adult patients thin enough to allow easy manual arrest, bone marrow or growth plate damage, and fat
insertion is the sternal manubrium. With the advent of the embolism exists. However, animal studies and autopsy
new IO devices, this issue is no longer a problem because investigations have not substantiated these potential
the devices are easily able to penetrate the hard cortical sequelae.16,19,44Y46 Fat embolisms may occur on a micro-
bone of older children and adults and allow for more reli- scopic level, but they are so small they do not seem to be
able and safer access.5 clinically relevant.46 There are only a few reports of death
from complication of IO needle placement into the sternum
caused by mediastinitis, hydrothorax, and cardiac or great
USES/COMPLICATIONS/CONTRAINDICATIONS vessel injury.47
The effectiveness of IO delivery of fluids, blood In the largest literature review of IO cases, Rosetti
products and medications has been demonstrated in numer- et al24 in 1985 examined 4270 cases and found the most
ous studies since its implementation in the 1940s. Based frequently reported adverse effect to be osteomyelitis, with
upon these studies involving both human and animal an incidence rate of 0.6%. In their report, all the cases of
models, the general consensus is that all resuscitation drugs, osteomyelitis resulted after prolonged infusions. Therefore,
blood products, and fluids can be safely administered via the it has been suggested that this relatively rare complication
IO route to both children and adults.2Y8,16Y22 The onset of can be reduced even further if alternative venous access is

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Blumberg et al Pediatric Emergency Care  Volume 24, Number 1, January 2008

obtained shortly after initial stabilization.24,46,48 Extravasa-

tion of fluids can occur because of incomplete penetration of
the cortex on IO insertion, penetration of the needle through
the posterior aspect of the cortex, or through a bone that has
holes established from previous attempts or from a fracture.
In its most severe form, this extravasation can produce a
compartment syndrome.48Y51 However, most of the cases in
the literature of compartment syndrome occurred in patients
in whom there was prolonged infusion of IO fluids and
medications or in whom there were multiple attempts made
on the same bone. Concerns about growth plate injuries
have also been raised, although they have not been sub-
stantiated by animal studies. In 2 separate studies by
Brickman et al,16 there were no growth disturbances or
growth plate abnormalities in infant porcine models that
underwent IO infusion and were followed for 6 months
clinically, radiographically, and histologically. Claudet
et al52,53 followed, with radiography, pediatric patients in
whom an IO was placed for an average of 21/2 years and FIGURE 2. Cook Critical Care Intraosseous Needle (reprinted
found no long-term effect on tibial growth. In general, most with permission from Cook Critical Care).
complications can be avoided with careful placement,
monitoring, and prompt removal of the IO needle once compared 1 needle with another and have found differences
venous access is available. in preferences and time to insertion, all seem to be effective,
quick, and easy to use.54
MANUAL NEEDLES The technique for insertion of manual needles is taught
Intraosseous infusions were first attempted with butter- during PALS and involves placing the needle by using a
fly needles and spinal needles. However, their use is no turning motion. Once the needle passes through the cortex of
longer routinely recommended because these needles have a the bone and into the marrow space, a decrease in resistance
greater likelihood of bending or becoming occluded. There is felt. The stylet is then removed. Bone marrow may be
are currently several different manual IO needles commer- aspirated to confirm proper placement, but this is not always
cially available. They are all basically modified steel needles successful. Alternative means of documenting proper place-
with central removable trocars that prevent plugging during ment of the IO include: lack of resistance during infusion of
insertion.12 A needle with a stylet is recommended so that it 5 to 10 mL of saline, no evidence of extravasations of the
does not become occluded with bone on insertion. The most fluid, and needle feels firmly in place. Once placement is
widely used manual IO needles include the Jamishidi/Illinois confirmed, the IO is secured using tape and gauze dressings.
(Cardinal Health, McGaw Park, Ill) (Fig. 1), the threaded An infusion of lidocaine has been shown to decrease the
Sur-Fast needle, and the Dieckman modified needle (both visceral pain associated with infusion in awake adults. The
by Cook Critical Care, Bloomington, Ind) (Fig. 2). These dose of 2% preservative-free lidocaine is 0.5 mg/kg for
needles are all relatively similar, and the technique for their patients between 3 and 39 kg and between 20 and 40 mg in
insertion is comparable. Although some researchers have

FIGURE 1. Jamishidi needle (reprinted with permission from FIGURE 3. The FAST 1 System (reprinted with permission
Cardinal Health). from Pyng Medical Corporation).

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Pediatric Emergency Care  Volume 24, Number 1, January 2008 A Review of Intraosseous Infusion Methods and Devices

patients heavier than 39 kg.12 The IO needle can then be

connected to standard IV tubing, although it may require
higher infusion pressure than a standard IV line, which can
be achieved by infusion manually via a syringe or by
attaching a pressure bag to the IV bag.

MECHANICAL IO DEVICES
There are currently 3 Food and Drug Administration
(FDA)Yapproved mechanical IO devices available in the
United States. These include 2 spring-loaded devices, the
Bone Injection Gun (BIG; WaisMed, Yokneam, Israel) and
the FAST 1 (Pyng Medical Corporation, Vancouver,
Canada), and 1 type of powered drill, the EZ-IO (VidaCare
FIGURE 5. The BIG pediatric and adult devices (reprinted
Corporation, San Antonio, Tex).
with permission from WaisMed).
The FAST 1 System is the first mechanical IO device
to be approved by the FDA in 1997 (Fig. 3). It is a sterile
disposable system designed for adult IO access in the placed in the target zone (Fig. 4). A push on the introducer
sternum. The device uses a probe composed of multiple releases the infusion tube into the site to the correct
needles that properly aligns the device with the patient_s penetration depth. The introducer is then pulled back, and
sternum. Manual pressure, with the assistance of a spring- the infusion tubing is left in place and then connected to a
loaded needle, then triggers the device to penetrate directly source of fluid. Finally, a protective hard dome is placed
into the sternal medullary cavity. The design of the device over the target patch and infusion tube and serves to secure
with its bed of needles ensures that the operator will not the device and allow chest compressions to be performed
penetrate through the sternum. directly over the dome. Once IO access is no longer
required, the FAST 1 infusion tube is disengaged by a
Each FAST 1 System includes an introducer, infusion
remover that threads into the inside of the infusion tube tip
tube, target patch, protective dome, instructions, tube
and allows the tube to be pulled from the bone. An initial
remover, and skin-sanitizing products. The technique for
study by Johnson et al55 found that after 2 hours of training,
using the device involves placing a target patch on the
paramedics and doctors were able to successfully insert
patient_s manubrium, in the midline 1.5 cm below the sternal
the device into cadavers within 90 seconds and achieved
notch. After the patch is securely attached, the introducer is
flow rates up to 250 mL/min with syringe infusion. In
2005, Miller et al56 studied 29 basic emergency medical
technicians who were given 2 hours of instruction and
then observed using the FAST 1 on mannequins. All
correctly applied the target patch, 55% achieved successful
IO needle deployment on the first attempt, and 93% were
successful within 4 attempts. The company is presently
researching the feasibility of the FAST 1 in adolescents
and preadolescents.

FIGURE 4. The FAST 1 Introducer (reprinted with permission FIGURE 6. The BIG insertion technique (reprinted with
from Pyng Medical Corporation). permission from WaisMed).

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Blumberg et al Pediatric Emergency Care  Volume 24, Number 1, January 2008

The BIG is a small automatic plastic disposable IO

injector (Fig. 5). It features a spring-loaded device with a
trigger. Once the safety pin is removed from the device and
the trigger is pressed, a spring shoots the IO needle through
the cortex. The pediatric version is indicated for children
younger than 12 years, contains an 18-gauge needle, and
has an adjustable insertion depth of between 0.5 and 1.5 cm.
The insertion site in adults and children is adjacent to the
tibial tuberosity.
The BIG is positioned 90 degrees to the surface of
the bone with 1 hand, the other hand removes the safety pin
and then releases the trigger (Fig. 6). The gun is then
removed, and the stylet trocar is pulled out. The IO cannula
is then attached to any standard IV system. Its use in the
proximal tibia was FDA-approved in 2000; however,
investigators have described its use in the radius, ulna, distal
tibia, and humerus.34,38 Spriggs et al57 compared time for FIGURE 8. The EZ-IO insertion (reprinted with permission
line placement and ease of insertion of the Jamishidi with from VidaCare Corporation).
those of the BIG among student and practicing paramedics
on a pediatric leg mannequin and found faster placement
time in the BIG group but no difference in ease of use and disposable drill-tipped needle work like a traditional
between the 2 groups (t = 16.91 seconds vs 11.93 seconds, drill and bit. The needle tip is placed on the insertion site at a
P = 0.02). Gilman et al58 in 2002 compared placement of 90-degree angle, the driver is held lightly in the dominant
traditional IO needles with that of the BIG in swine by hand and the trigger is pressed (Fig. 8). The driver drills the
emergency medicine residents, and found that placement specially designed hollow IO needle into the bone at a preset
time and success rate were similar in the 2 groups, and that length. The instructions state not to push the driver, but
the BIG was preferred by most users. Another study instead to allow the driver to do the work. The operator
examined the feasibility of BIG usage by operators in full should gently guide the needle and feel for the give that
biochemical protective gear compared with operators with- indicates penetration into the marrow space. The stylet is
out protective gear. They found insertion using the BIG to removed by unscrewing it, and then the needle is connected
be rapid and easy and to have potential benefit in situations to a standard Luer-Lok set. Just as with manual needles,
where emergency treatment after a toxic mass casualty is placement is confirmed by the needle being set firmly, by
required.59 noting blood or marrow on the stylet tip, aspirating blood or
The EZ-IO received FDA approval in 2004. This marrow from the needle, and noting that fluids flow without
device is a small battery-powered IO driver and needle set difficulty. The IO catheter can be removed in the same
(Fig. 7). According to the company, it has been successfully manner as a manual IO needle, by rotating it clockwise
used in more than 3300 patients worldwide and more than 76 while gently pulling back on the needle. The pediatric
pediatric patients in the United States. The reusable driver version, the EZ-IO PD, uses the same driver as the adult EZ-
IO and is approved for children lighter than 39 kg. Fifteen-
gauge needles that are 15-mm long are available for children
lighter than 39 kg, and 15-gauge 25-mm long needles are
used for patients heavier than 39 kg.
In the United States, the EZ-IO has been approved for
use at 2 anatomical sites, the proximal tibia and the humeral
head. In a company-initiated prospective study involving
250 patients older than 16 years, EMS providers had an
insertion success rate of 97%. On a visual analog scale from
1 to 10, among patients with a Glasgow Coma Scale greater
than 8, the average insertion pain score was 3.8, and the
average infusion pain score was 5.0. Patients who received
20 to 50 mg of 2% lidocaine had significantly less pain. The
study also revealed the importance of flushing the syringe
with 10 mL of saline before infusing so as to improve the IO
flow rate. A total of 23 different medications and fluids were
successfully administered.60 Another company-initiated
study reported on 125 patients during 9 months from
Montgomery County, Texas, who underwent EZ-IO inser-
FIGURE 7. The EZ-IO (reprinted with permission from tion in the field by EMS personnel. The IO was placed
VidaCare Corporation). secondary to hypovolemic shock, cardiac arrest, or failure to

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Pediatric Emergency Care  Volume 24, Number 1, January 2008 A Review of Intraosseous Infusion Methods and Devices

gain intravascular access after 2 attempts. There was an 4. Arbeiter HI, Greengard J. Tibial bone marrow infusion in infancy. J
insertion success rate of 94%, and the IO was placed on Pediatr. 1944;25:1Y16.
5. Dubick M. A review of intraosseous vascular access: current status and
average within 5 minutes of EMS arrival. There were no military application. Mil Med. 2000;165:552Y559.
complications reported, and the average infusion amount 6. Thompson B, Rice T. BPALS for life![ A required trauma-oriented
was 350 mL (20Y1500 mL).61 Pediatric Advanced Life Support course for pediatric emergency
In terms of military application, Calkins et al62 medicine and housestaff. Ann Emerg Med. 1984;13:1044Y1047.
7. Berg RA. Emergency infusion of catecholamines into bone marrow. Am
examined 4 of the devices. The threaded Surfast and J Dis Child. 1984;138:810Y811.
Jamishidi manual needles, the FAST, and the BIG were 8. Orlowski JP. My kingdom for an intravenous line. Am J Dis Child.
tested by military special operations personnel, and all of 1984;138:803.
the devices and techniques were found to be easy to teach, 9. International Liaison Committee on Resuscitation. Part 4: advanced life
learn, and use. Insertion times were comparable to IV place- support. Resuscitation. 2005;67:213Y247.
10. International Liaison Committee on Resuscitation. Part 6: paediatric
ment times. basic and advanced life support. Resuscitation. 2005;67:271Y291.
Each device seems to have its strengths and weak- 11. American Heart Association. Highlights of the 2005 American Heart
nesses, yet all seem to achieve rapid vascular access. Manual Association guidelines for cardiopulmonary resuscitation and emergency
IO needles have become standard of care in younger cardiovascular care. Curr Emerg Cardiovasc Care. 2005;16:1Y27.
12. Miller L, Kramer GC, Bolleter S. Rescue access made easy. JEMS.
children because of their long history of ease of use, safety, 2005;30:S8YS18.
and efficacy. The newer devices allow an expansion of the 13. Ross M, Romrell L, Kaye G. Histology, A Text and Atlas. 3rd ed.
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emergency department resuscitation rooms, prehospital tation. 2004;62:107Y112.
15. McCarthy G, O_Donnell C, O_Brien M. Successful intraosseous
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Although these experiences are compelling, we have yet to developmental and histopathologic changes from intraosseous infusion.
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AHA is currently sponsoring research involving IO access tonic saline dextran solution. Eur Surg Res. 1991;23:123Y129.
and IO devices. Presently under investigation is a new 18. Glaeser PW, Hellmich TR, Szewczuga D, et al. Five-year experience in
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IO injectors could be used in mass casualty situations. In infusions: risks of fat and bone marrow emboli to the lungs. Ann Emerg
addition, investigators are examining the effectiveness of Med. 1989;18:1062Y1067.
having automated external defibrillators preprogrammed to 20. Wagner MB, McCabe JB. A comparison of four techniques to establish
intraosseous infusion. Pediatr Emerg Care. 1988;4:87Y91.
recommend IO medications in certain situations. Studies are 21. Waisman M, Roffman M, Bursztein S, et al. Intraosseous regional
currently underway that examine clinical outcomes after IV anesthesia as an alternative to intravenous regional anesthesia. J
versus IO drug delivery as well as other studies that further Trauma. 1995;39:1153Y1156.
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is expected that further anatomical sites will be approved for 1997;42:288Y293.
23. Tocantins LM, O_Neill JF, Jones HW. Infusions of blood and other
placing IO needles including the humeral head, clavicle, fluids via the bone marrow: application in pediatrics. JAMA. 1941;
medial malleolus, radius, olecranon, and calcaneous.12 117:1229.
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osseous and intravenous CBC and Astra 8 in swine. Ann Emerg Med. 52. Claudet I, Alberge C, Bloom MC, et al. Intraosseous infusion in
1986;15:647. children [in French]. Ann Fr Anesth Reanim. 1999;18:313Y318.
37. Orlowski JP, Porembka DT, Gallagher JM, et al. The bone marrow as a 53. Claudet I, Fries F, Bloom MC, et al. Retrospective study of 32 cases
source of laboratory studies. Ann Emerg Med. 1989;18:1348Y1351. of intraosseous perfusion [in French]. Arch Pediatr. 1999;6:516Y519.
38. Grisham J, Hastings C. Bone marrow aspirates an accessible and 54. Halm B, Yamamoto LG. Comparing ease of insertion of intraosseous
reliable source for critical laboratory studies. Ann Emerg Med. 1991;20: needle placement: Jamishidi versus cook. Am J Emerg Med. 1998;16:
1121Y1124. 420Y421.
39. Brickman K, Krupp K, Rega P, et al. Typing and screening of blood 55. Johnson DL, Findlay LM, Stair TO, et al. Device for fast field
from intraosseous access. Ann Emerg Med. 1992;21:414Y417. intraosseous infusion via the adult manubrium. Ann Emerg Med.
40. Ummenhofer W, Frei F, Urwyler A, et al. Are laboratory values in bone 1998;32. [abstract #145].
marrow aspirate predictable for venous blood in paediatric patients? 56. Miller DD, Guimond G, Hostler DP, et al. Feasibility of sternal
Resuscitation. 1994;27:123Y128. intraosseous access by emergency medical technician students. Prehosp
41. Johnson L, Kissoon N, Fiallos M, et al. Use of intraosseous blood Emerg Care. 2005;9:73Y78.
to assess blood chemistries and hemoglobin during cardiopulmonary 57. Spriggs NM, White LJ, Martin SW, et al. Comparison of two
resuscitation with drug infusions. Crit Care Med. 1999;27:1147Y1152. intraosseous infusion techniques in an EMT training program. Acad
42. Heinild S, Sondergaard T, Tudvad F. Bone marrow infusion in Emerg Med. 2000;7:1168.
childhood: experiences from a thousand infusions. J Pediatr. 1947;30: 58. Gilman EA, Menegazzi JJ, Wang HE, et al. Traditional intraosseous
400Y411. needle vs spring loaded device in pediatric swine model. Acad Emerg
43. LaFleche FR, Slepin MJ, Vargas J, et al. Iatrogenic bilateral tibial Med. 2002;9:515.
fractures after intraosseous infusion attempts in a 3-month-old infant. 59. Ben-Abraham R, Gur I, Vater Y, et al. Intraosseous emergency access
Ann Emerg Med. 1989;18:1099. by physicians wearing full protective gear. Acad Emerg Med. 2003;10:
44. Moscati R, Moore GP. Compartment syndrome with resultant amputation 1407Y1410.
following intraosseous infusion. Am J Emerg Med. 1990;8:470Y471. 60. Davidoff J, Fowler R, Gordon D, et al. Clinical Evaluation of a novel
45. Christensen DW, Vernon DD, Banner W Jr, et al. Skin necrosis compli- intraosseous device for adults. JEMS. 2005;30:S19YS22.
cating intraosseous infusion. Pediatr Emerg Care. 1991;7:289Y290. 61. Gillum L, Kovar J. Powered intraosseous access in the prehospital
46. Simmons CM, Johnson NE, Perkin RM, et al. Intraosseous extrava- setting. JEMS. 2005;30:S23YS25.
sation complication reports. Ann Emerg Med. 1994;23:363Y366. 62. Calkins MD, Fitgerald G, Bentley TB, et al. Intraosseous infusion
47. Tocantins LM, O_Neil JF. Complications of intraosseous therapy. Ann devices: a comparison for potential use in special operations. J Trauma.
Surg. 1945;122:266. 2000;48:1068Y1074.

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Pediatric Emergency Care  Volume 24, Number 1, January 2008 A Review of Intraosseous Infusion Methods and Devices

CME EXAM
Instructions for the Pediatric Emergency Care CME Program Examination

To earn CME credit, you must read the designated article and complete the examination below, answering at least 80%
of the questions correctly. Mail a photocopy of the completed answer sheet to the Lippincott CME Institute Inc., 770 Township
Line Road, Suite 300, Yardley, PA 19067. Only the first answer form will be considered for credit and must be received by
Lippincott CME Institute, Inc. by March 15, 2008. Answer sheets will be graded and certificates will be mailed to each
participant within six to eight weeks after LCMEI, Inc. receipt. The answers for this examination will appear in the April
2008 issue of Pediatric Emergency Care.
Credits
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PRA category 1 Credit TM. Physicians should only claim credit commensurate with the extent of their participation in the
activity.
Accreditation
Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.

CME EXAMINATION
January 2008

Please mark your answers on the ANSWER SHEET.

Intraosseous Infusion: A Review Methods and Novel Devices, Blumberg et al
1. You are treating a febrile 14-year-old adolescent who immediately place an intraosseous needle and send
appears to have septic shock secondary meningococcal the aspirate to the laboratory as you begin an infusion of
infection. After several unsuccessful attempts at periph- isotonic sodium chloride solution. The results are hemo-
eral intravenous access and failed attempt at placing a globin, 10g/dL; white blood cell count, 42,000/2L,
catherer in the femoral vein, you decide to place an potassium, K 3.5 mEq/L; glucose, 48 mg/dL; and phe-
intraosseous needle. Which of the following sites has nytoin level, 18 2g/mL (therapeutic range 10Y20 mg/dL).
not been used successfully for intraosseous access? Based on these studies on the sample from the bone
a. Distal radius marrow, the most important treatment is:
b. Sternum a. blood.
c. Anterior iliac spine b. ceftriaxone.
d. Proximal femur c. potassium.
e. Clavicle d. glucose.
2. Paramedics arrive with a 3-year-old boy who has been e. phenytoin.
stuck by a car. He is unconcious and being manually 4. Significant complications from placement of an intra-
ventilated through an endotracheal tube with a pulse of osseous needle occur in what proportion of children?
190/min, a blood pressure of 65/20 mm Hg, and a a. 1%
distended abdomen. Having achieved intraosseous access, b. 5%
you are now able to administer: c. 10%
a. red blood cell. d. 15%
b. epinephrine. e. 30%
c. sodium bicarbonate. 5. Which of the following described the Bone Injection
d. calcium chloride. Gun?
e. all of the above. a. Approved for children up to age 16 years
3. The parent of a 6-month-old female infant with a history of b. Comes loaded with an 18 gauge needle
epilepsy rush into the emergency department holding their c. Depth of insert adjusts from 0.5 to 2 cm
daughter who is actively convulsing. On arrival, her vital d. Works on the basis of a drill mechanism
signs are: temperature, 40.2-C; pulse rate, 188/min; res- e. Approved in the United States for the tibia and
piratory rate, 42/min; blood pressure, 70/35 mm Hg. You femur

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Blumberg et al Pediatric Emergency Care  Volume 24, Number 1, January 2008

ANSWER SHEET FOR THE PEDIATRIC EMERGENCY CARE

CME PROGRAM EXAM
January 2008
Please answer the questions on page 57 by filling in the appropriate circles on the answer sheet below. Please mark the
one best answer and fill in the circle until the letter is no longer visible. To process your exam, you must also provide the
following information:
Name (please print): ______________________________________________________________________________________
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1. A B C D E
2. A B C D E
3. A B C D E
4. A B C D E
5. A B C D E
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[ ] Yes [ ] No
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[ ] Yes [ ] No
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Pediatric Emergency Care  Volume 24, Number 1, January 2008 A Review of Intraosseous Infusion Methods and Devices

CME EXAM ANSWERS

Answers for the Pediatric Emergency Care CME Program Exam

Below you will find the answers to the examination covering the review article in the October 2007 issue. All participants whose
examinations were postmarked by December 15, 2007 and who achieved a score of 80% or greater will receive a certificate from
Lippincott CME Institute, Inc.

EXAM ANSWERS
October 2007

1. B
2. B
3. A
4. E
5. D

* 2008 Lippincott Williams & Wilkins 59

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