[Angie O'Plasty, RN]

Where's the best location to choose? What gauge needle? How deep? Aspirate for blood return? How much flush and how often?

Try for an IJ first?

[DarrenWright]

Done many.

It depends on the patient (adult or pediatric), the needle type, and the urgency.

If you are using the traditional Jamshidi trocar on a pediatric (or even an adult), you will put it in the proximal tibia...sort of just medial to and below the knee. You will hold the needle firmly in your dominant hand, stabilize the extremity and the skin, and 'drill' into the bone going as straight with the needle as you possibly can. You will almost always 'feel' a pop as the tip of the needle stops meeting resistance and enters the medullary cavity, and you stop...that's how deep you go. I think the standard IO needle guages are around the 15 and 17 gauge variety...again, depends on the brand. You can let go of the needle, and the needle will stick straight up and hold itself reasonably in place.

You only need to aspirate enough to confirm placement, and sometimes even a successful placement will not provide any aspirate. If you don't get aspirate, but think you are in the right place, you can slowly infuse some crystalloid and see if the area around the puncture and on the back of the puncture site shows any swelling or increasing firmness.

Some needles are very specific; i.e. the FAST brand IO is designed for adult sternal placement. Very easy to use, but a brutal looking tool. The EZ-IO is like a drill; the manufacturer provides a video of unmedicated adult volunteers who get an IO placed by the EZ IO gun into their leg, and they said it was very tolerable. They said the infusion of fluid was more uncomfortable than the actual placement of the needle.

I think an IO is easier to place in an emergent situation than an IJ, but I would at least probably look and maybe try to place and External Jugular line before putting in an IO...but this decision should take less than a minute.

Lots on google.

[GilaRN]

My employer currently uses both the adult and pedi BIG. In addition, the sternal IO FAST and good old jamshidi (sp?) are utilized.

Aspiration of marrow will often not be possible. You can feel a pop and lack of resistance if you are using the older devices. You should be able to flush. Watch for swelling. If using the tibial plateu, monitor the posterior aspect of the lower leg. (calf swelling)
Each site has advantages and disadvantages. Every site has advantages and pitfalls. For example, the tibial plateau would be a poor choice in a patient with crushed legs, while a patent who sustained a sternal fracture from smashing into a steering wheel would not benefit from the FAST.

We do not perform internal jugular punctures.

[scattycarrot]

As far as i aware the AHA teach IO access if you cannot get periperal in an emergency situation. One reason is that IO is not contraindicated in coagulopathy.

[EDValerieRN]

You can also use a regular large-bore needle (18g or bigger) if the poop hits the fan. We use Jamshidis on the kids, and we just got the IO drill (forget the name, think it's called EZ-IO) on the adults. If you've taken PALS, it feels a lot like the chicken bone, only with less resistance after the pop.

Depending on the situation, I don't think I would mess around too much trying to get a line.. the rule of thumb is three tries or ninety seconds, and then give 'em an IO.

[Dolce]

I just finished the ACLS refresher course and the new AHA guidelines specify making two attempts at IV access and then proceeding directly to IO. I've personally never done IO access.