We’ve all experienced the scenario where a trauma patient appears in your trauma bay, blood pressure barely palpable, whose IV line is near impossible to obtain. Solution? IO access. A wonderful advancement in trauma care that has led to the stabilization of critically ill patients in whom IV access cannot be immediately obtained. IO is useful for medications and IV fluids. That’s great. However, in trauma patients, immediate CT with IV contrast for evaluation is often needed. If you don’t have IV access, can you use an IO line?
Duncan et al. completed a study to investigate IO administration of contrast material in the adult porcine (mini-swine) model in trauma-protocol enhanced CT scans. IO lines were placed in the proximal humerus with fluoroscopic confirmation. IO and IV power-injected contrast studies were completed. 2 board certified radiologists read all scans. All images showed adequate vascular opacification in all animals [1].
Miller et al. did in vivo research with goats to test IO access in the delivery of contrast via power injector for CT scans; they also completed a bench study to evaluate the maximum pressure that could be safely delivered through the IO route: with extension tubing and without (directly into IO catheter). They found that IO access was effective for diagnostic CT contrast administration, particularly in the humerus (2 injections into the tibia led to distal venous ruptures around the periphery of the bone). The intraosseous tubing ruptured at times with pressure and should not be used for CT studies using the power injector, especially if the IO site is the tibia [2].
Ahrens et al. published a case report in the Journal of Emergency Medicine in which a successful pulmonary artery CTA was obtained via contrast injection into the tibial IO line of an adult patient [3].
Knuth et al. published a case report of an adult blunt trauma patient with successful administration of iodinated contrast for CT scans of thorax, abdomen and pelvis with a resulting adequate study and no complications reported. Access was obtained in the proximal humerus [4].
Certainly, further studies in human subjects is warranted, but the IO route appears to be a safe and feasible method to deliver contrast for CT scans in patients requiring urgent scanning in whom IV access cannot be obtained. Hand-injection by radiologists with a timed study may be prudent without enough evidence of power-injection at this time.
References:
1. Duncan L et al. Intraosseous administration of CT contrast in a porcine model: A feasibility study. Annals of Emergency Medicine. 2012; 60 (4): 92.
2. Miller LJ et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4), 240-241.
3. Ahrens K et al. Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report. The Journal of Emergency Medicine. 2013; 45 (2): 182-184.
4. Knuth et al. Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals of Emergency Medicine. 2011; 57 (4): 382-386.
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2 Comments
jkhadpe · April 13, 2014 at 6:35 pm
Interesting topic- would be nice to see some bigger studies on this. Seems like humerus would be the way to go for now but would imagine many radiologists would not feel comfortable to give via IO yet. Wonder if any trauma centers have a protocol in place to give contrast via IO.
Mark Silverberg · April 14, 2014 at 12:18 am
Just because people say you can do it does not mean you should. If the patient is so unstable that you are sending them to CT immediately, then maybe you should not be sending them to CT at all. Get the IO in, give the meds you need or fluids but start to work on the peripheral/central line. In the patient that needs a CT with IV contrast, I would put in a central line and then send them to CT. In my opinion, IO lines are temporary lines until you can get better access. Just my 2 cents.