The potential use of intraosseous (IO) infusions for adults was first examined 80 years ago. Until very recently, this procedure was most commonly considered a rescue technique for pediatric patients, and then only after all else had failed. However, the use of IO access is making a comeback! Once again, it is being recognized as a valuable adjunct to adult, as well as pediatric, fluid and medication administration. This change has taken place primarily as a result of increasing recommendations to more rapidly consider the IO route, extend usage beyond our youngest patients and evaluate the potential of new and improved devices.

This article reviews the indications for pediatric and adult IO placement, addresses many of the concerns associated with the procedure and introduces several new devices available for this potentially lifesaving technique.

Intraosseous infusion is "an effective, reliable and relatively simple technique, both for obtaining rapid vascular access and for the administration of fluids and medications in the emergency setting."1

It is well known that establishing intravenous access in an infant or young child is challenging even under normal circumstances.2 In the prehospital and emergency department settings, few things provoke generalized apprehension like the need to place an intravenous line in a critically ill child. Experienced nurses and paramedics know that it is hard enough to start an IV on a healthy child, not to mention one who is sick or injured. To make matters worse, add the effects of vasoconstriction to naturally small veins, and the result is a situation that most providers would simply describe as a nightmare.

Although a potential solution for this problem was first suggested over 80 years ago, it was generally restricted to resuscitating critically ill children. Since the 1920s, it has been recognized that the bone marrow functions as a "non-collapsible" vein and is able to provide a route for rapid vascular access.3,4 This medical breakthrough had important applications, especially for pediatric resuscitation, because children may not seem to have veins, but they always have tibias. Recent developments have made IO access an even more important tool in our arsenal of available options that can be used for the sickest kids and adults as well.

Despite widespread use of venous catheters, it is recognized that potential major limitations of prehospital resuscitation relate to time delays and failure rates associated with obtaining vascular access.4