• 
• 

Three Part Question

[In adult patients with suspected acute pulmonary embolism in which intravenous access is unable to be obtained], does [intraosseous access (IO)] provide [sufficient image quality for a CT angiogram of the thorax to diagnose a pulmonary embolism].

Clinical Scenario

The patient is a 40-year-old obese but otherwise healthy woman with history of recent knee surgery 1 week ago who presents to the ED with shortness of breath that began suddenly 4 hours ago. You suspect pulmonary embolus with her presentation but, due to her body habitus, intravenous access cannot be established. As you prepare to place a central line, a colleague suggests using an IO catheterization device for administration of iodinated contrast media.

Search Strategy

Medline 1966-06/18 using PubMed, Cochrane Library (2018), and Embase
[(exp intraosseous) AND (exp angiography OR exp contrast or exp pulmonary emboli)].

Search Outcome

355 articles were identified; there were no clinical studies that addressed the clinical question

Comment(s)

Most patients with suspected pulmonary embolus require computed tomographic angiography as part of their diagnostic workup. Pulmonary angiography requires intravenous access for contrast media injection. Peripheral intravenous access is preferred for this purpose but is not always achievable. In such circumstances, central lines can be used for contrast media injection. In instances when central line placement is inexpedient or impossible, IO access may be an effective alternative. The literature provides only four case reports where IO was used to administer iodine-based IV contrast material, with no complications noted, and all imaging examinations were diagnostically adequate (1-4). Winkler et al evaluated the safety and quality of performing computed tomographic angiography in trauma patients using IO needle intravenous access for contrast media injection (5). Although their evaluation was limited to the thoracic aorta, IO access was found to be a rapid, effective, and safe alternative to both peripheral and central venous access in the critically ill patient. Despite the scarcity of clinical evidence, radiology departments in the United States are publishing guidelines and institutional protocols for the emergent administration of iodinated contrast media via the intraosseous route (6,7). References 1. Knuth TE, Paxton JH, Myers D. Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Ann Emerg Med 2011; 57:382–386 2. Cambray EJ, Donaldson JS, Shore RM. Intraosseous contrast infusion: efficacy and associated findings. Pediatr Radiol 1997; 27:892–893 3. Geller E, Crisci KL. Intraosseous infusion of iodinated contrast in an abused child. Pediatr Emerg Care 1999; 15:328–329 4. Ahrens KL, Reeder SB, Keevil JG, Tupesis JP. Successful computer tomography angiogram through tibial intraosseous access: a case report. J Emerg Med 2013; 45:182–185. 5. Winkler M, Talley C, Woodward C, Kingsbury A, Appiah F, Elbelasi H, Landwher K, Xingzhe L, Fleischmann D. The use of intraosseous needles for injection of contrast media for computed tomographic angiography of the thoracic aorta. J Cardiovasc Comput Tomogr. 2017;11:203-207. 6. Baadh AS, Singh A, Choi A, Baadh PK. Katz, DS, Harcke HT. Intraosseous vascular access in radiology: review of clinical status. Am J Roentgenol 2016;207:241-247. 7. Yale School of Medicine. YDR CT intraosseous iodinated contrast injection policy. Yale School of Medicine website. radiology.yale.edu/patientcare/ policies/intraosseousneedlecontrastinjection.aspx. Published October 1, 2014. Accessed June 2, 2018

Clinical Bottom Line

In patients with suspected pulmonary embolism, there are no clinical trials suggesting that IO access is a suitable alternative for the injection of contrast media. Institutional guidelines recommending IO injection of contrast for CT angiography are based on animal studies and anecdotal reports.