Clinical Communications: Adults
Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report

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Abstract

Background

Intraosseous access has been used increasingly with proven efficacy in emergent situations for adults when intravenous access could not be obtained.

Objective

Our aim was to demonstrate if tibial intraosseous (IO) is an effective route for iodinated contrast administration and pulmonary vasculature visualization.

Case Report

We report on an obtunded patient requiring a computed tomography angiogram to help with diagnosis and tibial IO was the only viable access appropriate to withstand the pressure of a computed tomography iodinated contrast load. Tibial IO access was used successfully for administration of iodinated contrast to evaluate for massive pulmonary embolism in an obtunded patient in extremis secondary to cardiovascular instability.

Conclusions

The pulmonary arteries were opacified and demonstrated a high-quality CT angiogram can be done via tibial IO device.

Introduction

Intraosseous (IO) access has been increasingly used with proven efficacy in adults when intravenous (IV) access cannot be obtained. IO access for administration of various infusates, including colloids, blood products, and medications, with minimal, if any, complication has been successful (1). IO access was originally designed in the early 1920s for battlefield resuscitations and was used extensively by military medics throughout World War II. However, its use subsequently declined, possibly because of a lack of widespread use of paramedic/Emergency Medical Technician services at that time in the continental United States 1, 2. In the past 2 decades, however, there has been a resurgence of IO access after improvements in design. IO is now being used regularly on military frontlines for treatment of trauma and hemorrhagic shock, more recently in adult and pediatric patients 3, 4, 5, 6. In addition, it is increasingly used in the adult population, is currently considered a standard alternative to IV access, and is now endorsed as a class IIA guideline by the Advanced Trauma Life support, Advanced Cardiovascular Life Support, and Pediatric Advanced Life Support courses 5, 6. Benefits include the ability to gain noncollapsible access in hypovolemic patients or in those with difficult venous access, as well as the speed and relative ease of device placement 7, 8.

Although complications of IO use have been documented, they are infrequent and rarely involve significant morbidity. In both pediatric and adult populations, the most frequent documented complication is extravasation, with a prevalence of 0.8% (8). Other rare complications have primarily been reported in the pediatric population and include cellulitis (0.7%), osteomyelitis (0.6%), fat embolus, and compartment syndrome 7, 8, 9, 10, 11. Despite documented benefits, clinicians have been less inclined to use IO access to administer iodinated contrast for computed tomographic (CT) imaging because no formal studies exist and many unknown variables have yet to be identified, including local effects within bone medulla and unknown systemic effects. To date, only two reports of IO iodinated contrast administration have been described in the pediatric population and only a single report exists for an adult trauma patient 4, 12, 13. In this report, we describe IO administration of iodinated contrast for a contrast-enhanced CT pulmonary angiogram in a 54-year-old male in extremis, who presented with Pulseless Electrical Activity (PEA) and high suspicion for massive pulmonary embolus, demonstrating an effective high-quality CT angiography study can be generated from iodinated contrast given through a tibial IO device.

Section snippets

Case Report

A 54-year-old male with history of coronary artery disease and coronary stent placed in 2005 presented after complaining of chest pain with witnessed syncope and collapse. The patient was in PEA, IV access was unable to be obtained in the field. Paramedics obtained access via a left tibial IO catheter (EZ IO®, 15G, 25-mm length, 304-stainless steel needle; Vidacare, San Antonio, TX). The patient was then stabilized in the field by Advanced Cardiovascular Life Support. The patient was brought to

Discussion

This case demonstrated that a tibial (distal) IO device could be used for access to obtain an effective CT angiogram for pulmonary or thoracic vasculature imaging. The IO device could deliver the contrast at the speed and pressure required to provide without compromising access or the device. The first documented use of IO access for iodinated contrast was reported in 1997 in a 2-year-old child with a closed-head injury undergoing a contrast enhanced CT scan to assess for abdominal and pelvic

Conclusions

To date, only a single patient has survived an IO push of IV contrast, thus the long-term safety of this method remains unknown. This case report demonstrated that iodinated contrast agents can be administered through tibial IO access, producing a high-quality diagnostic CT angiogram. Although an insufficient conclusive demonstration of efficacy and safety, this report suggests that IO administration of iodinated contrast can be a viable option in acutely ill patients lacking IV access and

References (15)

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