Intraosseous and intravenous vascular access are equally effective for ROSC following out-of-hospital cardiac arrest

1. In this randomized clinical trial, among patients who had an out-of-hospital cardiac arrest, no significant difference was found in sustained return of spontaneous circulation between intraosseous and intravenous vascular access.

2. Rates of survival and survival with a favorable neurologic outcome at 30 days were also similar between the two groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Out-of-hospital cardiac arrest is a common event that is associated with high mortality. Current international guidelines recommend the use of epinephrine, in some cases in combination with amiodarone or lidocaine, in these situations, and administration of these drugs requires the establishment of vascular access. Both intravenous and intraosseous vascular access are routinely attempted during out-of-hospital cardiac arrest for this purpose, but international guidelines recommend the use of intravenous access, albeit with a very low certainty of evidence. The present trial assessed the efficacy of intraosseous vascular access compared with intravenous vascular access for sustained return of spontaneous circulation during out-of-hospital cardiac arrest. Compared with intravenous vascular access, intraosseous vascular access resulted in similar incidences of sustained return of spontaneous circulation. Furthermore, there were no significant differences in survival at 30 days or survival at 30 days with a favorable neurologic outcome between the two groups. Limitations of the study included treating clinicians being aware of trial-group assignments and the study not being powered for analysis of more patient-centered long-term outcomes, which would require a larger sample size. Nevertheless, these findings provide valuable insight that the efficacy of drugs given during cardiac arrest does not depend significantly on the route of administration.

Click to read the study in NEJM

In-Depth [randomized controlled trial]: This randomized superiority trial assessed the efficacy of intraosseous vascular access compared with intravenous vascular access concerning the sustained return of spontaneous circulation during out-of-hospital cardiac arrest. Patients 18 years of age or older for whom vascular access was indicated during an out-of-hospital cardiac arrest, and who did not have a suspected traumatic cause of the cardiac arrest, were included. The primary outcome was a sustained return of spontaneous circulation, defined as a palpable pulse or other signs of circulation with no further use of chest compressions for at least 20 minutes. A total of 1,479 patients were included in the study, with 731 assigned to the intraosseous group and 748 assigned to the intravenous group. A sustained return of spontaneous circulation occurred in 30% of patients in the intraosseous group, compared with 29% of patients in the intravenous group (risk ratio, 1.06; 95% Confidence Interval [CI], 0.90 to 1.24; P=0.49). Additionally, at 30 days, 12% of patients in the intraosseous group were alive, compared with 10% of patients in the intravenous group (risk ratio, 1.16; 95% CI, 0.87 to 1.56) and 9% of patients in the intraosseous group had a favorable neurologic outcome compared with 8% in the intravenous group (risk ratio, 1.16; 95% CI, 0.83 to 1.62). With regard to safety, adverse events were uncommon and limited to extravasation, bradyarrhythmia, and ventricular tachyarrhythmia. In summary, among patients who had an out-of-hospital cardiac arrest, there was no significant difference in sustained return of spontaneous circulation, survival at 30 days, or survival at 30 days with a favorable neurologic outcome between patients who underwent intraosseous vascular access compared with intravenous vascular access.

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