UMEM Educational Pearls

Category: Neurology

Title: Intraosseous Administration of Hypertonic Saline

Keywords: 23.4%, mannitol, intracranial hypertension, herniation, IO (PubMed Search)

Posted: 4/11/2019 by WanTsu Wendy Chang, MD (Updated: 7/5/2020)
Click here to contact WanTsu Wendy Chang, MD

  • Hypertonic saline and mannitol are commonly used for management of acute intracranial hypertension and cerebral herniation.
  • The choice of medication is often limited by venous access.
  • 23.4% NaCl has been shown to decrease intracranial pressure in patients refractory to mannitol.
    • It requires administration through a central line to avoid sclerosis of the peripheral veins and tissue necrosis with extravasation.
  • Intraosseous (IO) access provides a more rapid route for 23.4% NaCl administration.
    • No complications were observed relating to IO insertion site.
    • Transient hypotension occurred in more patients who received 23.4% NaCl via IO vs. central line.

Bottom Line: Use of IO allows more rapid administration of 23.4% NaCl with no immediate serious complications.


Wang J, Fang Y, Ramesh S, et al. Intraosseous administration of 23.4% NaCl for treatment of intracranial hypertension. Neurocrit Care. 2019;30(2):364-371.

Follow me on Twitter @EM_NCC