Introduction: Obtaining vascular access in a low-weight neonate requires knowledge, experience, special materials and proper control of the scene. A attention in the pre-hospital setting is an important challenge faced by health professionals working in this field. 
In SAMUR-PC, medical attention given to critical patients younger than 3 years old makes up 0.7% of all critical patients, while patients younger than 1 years old are less than 0.3% of critical patients. Intraosseous puncture guarantees vascular access, as an alternative and almost the only viable option in critical infants at the first stages in prehospital emergency medical care.
 
Case presentation: We were alerted from a primary health care facility to treat a one-week-old infant weighing 2,300 grams at birth after 37 weeks of pregnancy, because of a witnessed cardiorespiratory arrest. There was a senior nurse included in the pre-hospital emergency medical team, with experience of about 20 IO punctures in infants between 3 and 12 months of age, weighing more than 5,000 kg in critical condition, some of them in cardiorespiratory arrest.
 
Management and Outcome: two IO access were placed with EZ-IO device, one in each proximal tibia. Both of them were lost due to poor bone consistency at the puncture site and as a result of the vibration during resuscitation maneuvers.  
When it happened, a stable intraosseous access was achieved at distal femur using a 25mm needle at 90-degree angle to the bone’s axis. The IO access was kept stable with a posterior splint during the resuscitation maneuvers until the patient was transferred to the hospital, as the only available vascular access. Through this IO access, adrenaline, sodium bicarbonate and glucose were properly infused.
 
Conclusions: In premature infants the use of the intraosseous route in the distal femur during cardiorespiratory arrest should be considered. This location could be more advisable than the proximal tibia, classically recommended

5 - Intraosseous (IO) access in neonate with birth weight 2300 g in cardiorespiratory arrest, a challenge in pre-hospital emergency care