Intraosseous Vascular Access in Radiology: Review of Clinical Status

The Efficacy of Intraosseous Access for Initial Resuscitation in Patients with Severe Trauma: A Retrospective Multicenter Study in South Korea

Background/Objective: In patients with severe trauma, intraosseous (IO) access is an alternative when intravenous (IV) access proves challenging. However, detailed insights into its utilization patterns and effectiveness are lacking. This study aims to evaluate the use and efficacy of IO access in hemodynamically unstable patients with trauma at level-1 trauma centers in South Korea. Methods: Data from six centers over 12 months were analyzed, focusing on patients with traumatic cardiac arrest or shock. Overall, 206 patients were included in the study: 94 in the IO group and 112 in the IV group. Results: The first-attempt success rate was higher in the IO group than in the IV group (90.4% vs. 75.5%). The procedure time in the IO group was also shorter than that in the IV group. The fluid infusion rate was lower in the IO group than in the IV group; however, the use of a pressure bag with IO access significantly increased the rate, making it comparable to the IV infusion rate. Further, regarding IO access, a humeral site provided a higher infusion rate than a tibial site. Conclusions: IO access offers a viable alternative to IV access for the initial resuscitation in patients with trauma, providing advantages in terms of procedure time and first-attempt success rate. The use of a pressure bag and a humeral site for IO access afforded infusion rates comparable to those associated with IV access.

Pre-hospital emergency medicine: a spectrum of imaging findings

The goal of emergency medical services (EMS) is to provide urgent medical care and stabilization prior to patient transport to a healthcare facility for definitive treatment. The number and variety of interventions performed in the field by EMS providers continues to grow as early management of severe injuries and critical illness in the pre-hospital setting has been shown to improve patient outcomes. The sequela of many field interventions, including those associated with airway management, emergent vascular access, cardiopulmonary resuscitation (CPR), patient immobilization, and hemorrhage control may be appreciated on emergency department admission imaging. Attention to these imaging findings is important for the emergency radiologist, who may be the first to identify a malpositioned device or an iatrogenic complication arising from pre-hospital treatment. Recognition of these findings may allow for earlier corrective action to be taken in the acute care setting. This review describes common EMS interventions and their imaging findings.

Resuscitation and Evaluation With Intraosseous Access: A Review of the Literature in Trauma and Non-Trauma Patients

According to trauma resuscitation guidelines, intraosseous (IO) access is appropriate when failure to gain intravenous (IV) access is present in trauma, burn, shock, or resuscitation settings for adults or when two failed attempts have been made in the resuscitation of a pediatric patient. However, their effectiveness and use have been debated due to concerns on flow rates, extravasation, compartment syndrome, and osteomyelitis. The objective of this review is to examine the current literature regarding intraosseous access in trauma resuscitation, focusing on interventions and complication rates.

Comparison of intraosseous and intravenous iodinated contrast administration for CT imaging in Hispaniolan Amazon parrots (Amazona ventralis)

Establishing and maintaining intravenous access for contrast medium during CT imaging can be difficult in birds due to their small size and thin walled vessels. Intraosseous (IO) catheters are an alternative to intravenous catheters and are often used for fluid or medication administration in birds. To determine the feasibility of IO iodinated contrast enhancement for CT in birds, 10 adult Hispaniolan Amazon parrots (Amazona ventralis) weighing 260-325 g, were enrolled in a prospective randomized blinded crossover group study to evaluate the differences in contrast route administration. The parrots underwent pre- and postcontrast CT scans using both routes of contrast administration with a wash-out period of at least 1 week between the two methods. Scans were evaluated subjectively for diagnostic quality and objectively with Hounsfield units measured over three organs: the brain, right kidney, and liver. All scans were diagnostic, and there was no statistically significant measurable difference in contrast enhancement between the two methods in any of the three organs. Subjectively, IO catheters were technically more difficult to place, but once in place, they were easier to manipulate for the imaging procedure and provided no complications upon removal. Minimal adverse side effects were noted from the IO catheters. In this small study, IO iodinated contrast administration was comparable in enhancement characteristics to intravenous administration for CT imaging in Hispaniolan Amazon parrots.

Clinical Management of Intraosseous Access in Adults in Critical Situations for Health Professionals

There are health professionals who are unaware of the ideal management of the intraosseous route, despite the fact that it has been scientifically considered an alternative to the peripheral venous route when the patient is in critical condition. Thanks to continuous development, there has been a need to provide emergency services with materials that manage to provide satisfactory care, despite the difficulties faced by health personnel.

OBJECTIVES

The objective of this systematic bibliographic review is to update the theoretical and practical knowledge and strategies for the insertion and proper management of the intraosseous route as an emergency vascular access for nursing professionals. Data sources, study eligibility criteria: The search for the articles was carried out in various scientific databases with the help of a search string (January 2015 and May 2021), which combined the keywords and Boolean operators.

STUDY APPRAISAL AND SYNTHESIS METHODS

Eighteen articles were chosen after a review of 1920 database articles, following the application of the inclusion and exclusion criteria.

RESULTS

Intraosseous infusion is an effective and safe technique, which increases patient survival. Therefore, it is of crucial importance that all nursing professionals know how to handle the different intraosseous devices in situations in which it is not possible to achieve immediate peripheral venous access. Conclusions and implications of key findings: It is of great need to have devices or fast and effective alternatives that allow us to develop safe interventions by health professionals.

Sternal Intraosseous Devices: Review of the Literature

Introduction

The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased.

Methods

The authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review.

Results

Sternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR.

Conclusion

The sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.

Intraosseous contrast administration for emergency stroke CT

Computed tomography (CT) imaging in acute stroke is an established and fairly widespread approach, but there is no data on applicability of intraosseous (IO) contrast administration in the case of failed intravenous (IV) cannula placement. Here, we present the first case of IO contrast administration for CT imaging in suspected acute stroke providing a dedicated CT examination protocol and analysis of achieved image quality as well as a review of available literature.

Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making

Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.

Intraosseous contrast administration for emergency computed tomography: A case-control study

OBJECTIVE

The aim of the study was to evaluate the feasibility of intraosseous (i.o.) contrast media injection (CMI) for emergency computed tomography (CT) of severe trauma and the associated image quality compared to intravenous (i.v.) CMI.

MATERIALS AND METHODS

The authors retrospectively analysed objective (contrast-to-noise ratio (CNR)) and subjective (4-point Likert scale) image quality of CTs after i.o. (n = 4, mean age (y) 57.0±11.0) versus i.v. (n = 20, mean age (y) 58.8±4.4) CMI. All patients underwent a native head CT scan, a cerebral CT angiography (CTA) and CTA of the supra-aortic vasculature as well as a chest and abdominal CT scan in the venous phase; one patient with an i.o. access additionally received a CTA of the lower limbs. Electronic patient records have been reviewed to determine i.o. access related complications.

RESULTS

Both groups were consistent in age, heart rate, scan parameters including the flow rate of the contrast agent, resulting in comparable radiation dose levels. The image noise and CNR had no significant difference between the two groups. Scoring the delineation of the main vessels after i.o. CMI showed no significant difference to the i.v. group. There were no CT or i.o. access related complications observed.

CONCLUSION

The i.o. access is a safe and suitable alternative for emergency CMI in CT. Using established protocols good to very good image quality can be achieved, comparable to i.v. CMI. We show for the first time, that i.o. CMI is also feasible for CTA imaging of the head and neck region as well as of pelvic and leg vessels.

Intraarticular extravasation, an unusual complication of computed tomographic angiography performed with intraosseous needle intravenous access

Off label use of intraosseous needles (IONs) for contrast media (CM) injection during computed tomographic angiography (CTA) has been reported in small case series and isolated case reports. Presently, complications specific to this novel indication are essentially unknown. In this communication, we report an extravasation of CM from the intramedullary space of the humerus into the glenohumeral joint space during an ION injection of CM during a CTA of the head, neck, and chest. Although clinically insignificant in this case, a more severe intraarticular extravasation could have had both short or long term adverse sequelae. Practitioners of CTA should be aware of this potential complication.

Applied anatomy for tibial intraosseous access in adults: A Radioanatomical Study

Intraosseous access is a method for providing vascular access in resuscitation of critically ill and injured patients when traditional intravenous access is difficult or impossible. There is a lack of detailed description for the landmark for the insertion point in the literature. The aim of this study was to determine the exact location for intraosseous access. Radiographic computed tomography (CT) images of a total of 50 dry tibia bones were obtained. With 5-mm intervals, for all transverse images and by selecting transverse section, measurements were taken from the thickness of the cortex at anterior margin and mid-line medial surface, distance from anterior margin, and mid-line medial surface of the tibia to the posterior wall of medullar cavity, distance from anterior margin and mid-line medial surface of the tibia to the posterior surface of the tibia. The thinner part of the cortex of the tibia and the larger width of the medullar cavity is at 0.5 cm below the tibial tuberosity in the midline of the medial surface. The application region for proximal tibia access and landmark and most suitable insertion point for intraosseous infusion should be at level 0.5 cm below the tibial tuberosity in the midline of the medial surface. It was recommended that standard length for intraosseous canule should be 17 mm except for the thickness of skin. In conclusion, presented study provides certain localization for intraosseous access and standard length for intraosseous canule and this will be more effective in using this technique. Clin. Anat. 31:593-597, 2018. © 2017 Wiley Periodicals, Inc.

The use of intraosseous needles for injection of contrast media for computed tomographic angiography of the thoracic aorta

Background

The objective of this study is to evaluate the safety and quality of computed tomographic angiography of the thoracic aorta (CTA-TA) exams performed using intraosseous needle intravenous access (ION-IVA) for contrast media injection (CMI).

Methods

All CTA-TA exams at the study institution performed between 1/1/2013 and 8/14/2015 were reviewed retrospectively to identify those exams which had been performed using ION-IVA (ION-exams). ION-exams were then analyzed to determine aortic attenuation and contrast-to-noise ratio (CNR). Linear regression was used to determine how injection rate and other variables affected image quality for ION-exams. Patient electronic medical records were reviewed to identify any adverse events related to CTA-TA or ION-IVA.

Results

17 (~0.2%) of 7401 exams were ION-exams. ION-exam CMI rates varied between 2.5 and 4 ml/s. Mean attenuation was 312 HU (SD 88 HU) and mean CNR was 25 (SD 9.9). A strong positive linear association between attenuation and injection rate was found. No immediate or delayed complications related to the ION-exams, or intraosseous needle use in general, occurred.

Conclusion

For CTA-TA, ION-IVA appears to be a safe and effective route for CMI at rates up to 4 ml/s.