Intraosseous Needle Placement Confirmation by Doppler Ultrasonography

Abstract

SESSION TITLE: Rapid Session: Bedside Imaging SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: The 2015 guidelines for advanced cardiac life support (ACLS) recommend intraosseous (IO) access, if intravenous (IV) access is not readily attainable. The safety record for IO access is excellent. However, serious complications have been reported in the literature. In our institution, we experienced a limb threatening complication from a dislodged IO line despite standard confirmation. A properly placed IO line must be through the cortex of the bone and situated within the marrow cavity. Standard methods for confirmation of IO placement include aspiration of bone marrow, firm placement of the IO needle into the bone, and no evidence of extravasation. The traditional confirmation methods have as high as a 60% false positive rate for IOs that have incorrect penetrating placement, and a 10% false positive rate for incorrect subcutaneous placement. An alternative method to confirm IO placement is the use of color Doppler ultrasonography, which provides a noninvasive method for verification of correct IO placement. METHODS: Confirmation of correct IO placement was performed in a series of patients who received IO access during emergent resuscitation. Confirmation of IO placement with color Doppler was accomplished using a 7.5 MHz linear ultrasound probe placed adjacent to the IO site with the tomographic plane placed to intersect with the tip of the IO needle and the color Doppler map adjusted to target the needle tip area. Injection of 10 cc of agitated saline through the IO needle confirmed appropriate placement if the color signal showed subperiosteal color Doppler velocity pattern. The results of the color Doppler studies were compared to results of standard indices of IO placement. RESULTS: A total of 15 IO needle placements were studied. All were confirmed to be in appropriate subperiosteal position place using the three standard confirmation methods. The color Doppler technique confirmed placement in all 15 cases, indicating a perfect correlation between the methods. CONCLUSIONS: From this preliminary study, color Doppler ultrasonography may be a useful adjunct to standard confirmation techniques for intraosseous needle placement, as it allows for rapid identification of incorrect placement of IO lines, which in turn may prevent serious limb injury. The limitation of the technique is the requirement of operator training and machine availability. CLINICAL IMPLICATIONS: Using point-of-care color doppler ultrasonography helps quickly identify incorrect placement of IO lines. This, in turn, may help prevent serious, limb threatening injuries. DISCLOSURE: The following authors have nothing to disclose: Zubair Hasan, Karan Singh, Atul Palkar, Yonatan Greenstein, Paul Mayo No Product/Research Disclosure Information