Intraosseous administration of medications generally involves delivery via the medullary cavity of a long bone and has been used for decades (Vizcarra and Clum [360]).

This route can be used for emergency or short‐term treatment when access by the vascular route is difficult or impossible and the patient's condition is considered life threatening (Resuscitation Council [299]). It provides rapid systemic action of medications and fluids, while being more rapidly and easily achieved than other forms of central venous access. Unlike the peripheral vessels, the medullary cavity does not collapse in the presence of hypovolaemia or circulatory failure. It acts like a rigid vein, making it an ideal site in a situation where circulatory access is urgently required (e.g. clinical shock or cardiac arrest). The onset of action of medications administered via the intraosseous route is almost as rapid as conventional central venous delivery and considerably quicker than those given by the peripheral vessels. Medications can be delivered as a bolus injection or continuous infusion. The intraosseous route can also be used to obtain bone marrow samples for some emergency testing (e.g. cross‐match).

There are several insertion sites that may be considered, including the humerus, the proximal or distal tibia, and the sternum, and a range of intraosseous devices are available (Resuscitation Council [299]). Decisions concerning which site or device to use should be made locally, and staff should be adequately trained in the devices’ use before undertaking this procedure (Resuscitation Council [299]).

Any drug administered intravenously can be administered via the intraosseous route. Common indications for use of intraosseous devices are cardiac arrest, circulatory collapse, hypovolaemic shock, respiratory arrest, major trauma and emergency clinical situations (all advocated after two attempts at intravenous access or after 2 minutes of trying). However, this list is not exhaustive and administration may be based on the clinical judgement of a competent practitioner (Vizcarra and Clum [360]).

Contraindications include (Vizcarra and Clum [360]):

Fluids and blood products can also be given via the intraosseous route but need the application of pressure to achieve reasonable flow rates, ideally using a pressure bag.

Any attempt at intraosseous access must be undertaken by a clinical practitioner who has undergone appropriate education, training and assessment. Intraosseous access is usually carried out by a resuscitation officer.

Manufacturers recommend that the maximum length of time all intraosseous needles should stay in situ is 24 hours. It is good practice to document the time and location of insertion in the patient's medical and nursing notes (Resuscitation Council [299]).

Complications associated with the use of intraosseous devices are rare, but care must be taken during the insertion and use of such devices. Possible complications include: