Category: Critical Care
Keywords: cardiac arrest, ACLS, IV access (PubMed Search)
Posted: 11/5/2024 by Mark Sutherland, MD
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In out of hospital cardiac arrest (OHCA), does it matter if you choose an intraosseous (IO) vs intravenous (IV) approach to getting access and giving meds?
No, according to a recent study by Couper et al, just published in NEJM. No significant difference in any clinically meaningful outcome including survival, neurologically intact discharge, etc. Technically the IV group had slightly higher rates of ROSC, which just met statistical significance, and to be fair that group did trend very slightly towards better outcomes in some categories, but really well within the range expected by statistical noise.
Interestingly, the median time from EMS arrival to access being established was the same in both groups (12 minutes), which I think raises some face validity questions. Furthermore, of course, previous trials have raised questions as to whether ACLS meds even work or impact outcomes anyways, so naturally if they don't, the method by which they are given isn't likely to matter either.
Bottom Line: This large, well conducted trial continues to support the notion that either an IV-focused, or IO-focused approach to access and medication delivery in OHCA is reasonable. You and your prehospital colleagues can likely continue to make this decision based on personal comfort, local protocols, and patient/case circumstances. At the very least, this continues to support the notion that if an IV is proving challenging, pursuing an IO instead is a very appropriate thing to do.
Couper K, Ji C, Deakin CD, Fothergill RT, Nolan JP, Long JB, Mason JM, Michelet F, Norman C, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Starr KR, Walker A, Wood S, Bell S, Bradley G, Brown M, Brown S, Burrow E, Charlton K, Claxton Dip A, Dra'gon V, Evans C, Falloon J, Foster T, Kearney J, Lang N, Limmer M, Mellett-Smith A, Miller J, Mills C, Osborne R, Rees N, Spaight RES, Squires GL, Tibbetts B, Waddington M, Whitley GA, Wiles JV, Williams J, Wiltshire S, Wright A, Lall R, Perkins GD; PARAMEDIC-3 Collaborators. A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2024 Oct 31:10.1056/NEJMoa2407780. doi: 10.1056/NEJMoa2407780. Epub ahead of print. PMID: 39480216; PMCID: PMC7616768.
