Cardiology/original research
Intraosseous Versus Intravenous Vascular Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial

https://doi.org/10.1016/j.annemergmed.2011.07.020Get rights and content

Study objective

Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest.

Methods

This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access.

Results

There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes).

Conclusion

Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.

Introduction

Intraosseous needle insertion in the out-of-hospital setting is no longer exclusive to the pediatric population.1, 2 Recent studies have demonstrated that intraosseous needles can be a rapid method for obtaining vascular access in adult populations, particularly in the presence of failed peripheral intravenous line placement.3, 4, 5, 6, 7 As a result, intraosseous needle insertion is commonly used in the out-of-hospital setting when immediate vascular access is required during out-of-hospital cardiac arrest.

Across the United States, emergency medical services (EMS) systems have amended out-of-hospital protocols to include intraosseous needle insertions for both pediatric and adult patients in the setting of out-of-hospital cardiac arrest.8 Several anatomic locations (sternal, humeral, and tibial) are available for intraosseous needle insertions, but their actual effectiveness during out-of-hospital cardiac arrest resuscitation is unknown. The sternal location can prove difficult in out-of-hospital cardiac arrest because of ongoing chest compressions; both the proximal humerus and proximal tibia have been identified as safe locations in the out-of-hospital setting.5, 9, 10

There are limited data directly comparing the effectiveness of the humeral and tibial access sites during cardiac arrest. There is also a paucity of literature demonstrating that intraosseous access is more effective than peripheral intravenous access in the out-of-hospital cardiac arrest setting. Much of the research conducted in regard to intraosseous insertion has been observational and retrospective; currently, there are no known randomized controlled trials assessing the effectiveness of intraosseous vascular access sites.

Several studies, both animal and human, illustrate how quickly intraosseous needles can be inserted. Additionally, peripheral serum drug concentrations for medications administered through intraosseous sites were proven to be equivalent to those administered through peripheral intravenous lines.11, 12, 13 However, these studies were primarily conducted in controlled environments among sedated animals, humans with topical anesthesia, or human cadavers.14, 15 Furthermore, there are still concerns about discrepancies in the volume of fluid that can be administered between intraosseous sites and peripheral intravenous sites.16

In 2009, we conducted an observational study that found the tibial intraosseous placement to have a higher frequency of first-attempt success (80%) compared with the humeral intraosseous placement (40%) during out-of-hospital cardiac arrest.17 This represents a significant clinical difference when the delays to patient care that may occur as a result of failed vascular access in the out-of-hospital setting are considered. The objective of the current study was to assess the frequency of first-attempt success between the humeral intraosseous, tibial intraosseous, and peripheral intravenous routes during out-of-hospital cardiac arrest. It was hypothesized that a significant difference in the frequency of first-attempt success existed between tibial intraosseous needle insertions compared with humeral intraosseous needle insertions or peripheral intravenous access among patients experiencing out-of-hospital cardiac arrest.

Section snippets

Study Design and Setting

This study was a prospective, nonblinded, triple-arm, randomized controlled trial. The study was conducted by the Mecklenburg Emergency Medical Services Agency (Medic). Medic is a municipal all–advanced life support EMS agency with a coverage area of more than 500 square miles, serving a population of approximately 867,000 individuals. During the study period, annualized call volume was approximately 98,000, resulting in approximately 70,000 yearly patient transports. Patients were transported

Characteristics of Study Subjects

During the study period, there were 203 patients who experienced an out-of-hospital cardiac arrest, with 182 patients randomized to one of the 3 vascular access methods (Figure). The allocated method of vascular access was not used 13 times because of human error or situations beyond the control of the paramedic (9 in the humeral intraosseous group and 4 in the peripheral intravenous group). Characteristics of the study population overall and by method of vascular access are provided in Table 1.

Limitations

This study tested only 1 intraosseous device and insertion process and was not designed to test safety or the end outcome for out-of-hospital cardiac arrest, survival to hospital discharge. Also, the various time measures reported in our data analysis were documented on a cardiac arrest time log by the fire captain throughout resuscitation efforts. Although time of paramedic arrival on scene and arrival at the patient are captured by Medic dispatch, the fire captain was responsible for

Discussion

To our knowledge, this was one of the first randomized controlled trials to assess the frequency of first-attempt success between the humeral intraosseous, tibial intraosseous, and peripheral intravenous routes. Results demonstrated that the tibial intraosseous route was the most effective method of gaining vascular access during out-of-hospital cardiac arrest. The frequency of first-attempt success at the tibial intraosseous route exceeded that of both the humeral intraosseous and peripheral

References (20)

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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Supervising editor: Keith A. Marill, MD

Author contributions: RR, JRS, SV, and JG conceived the study and designed the trial. RR, JRS, and SV supervised the conduct of the trial and data collection. JRS and SV managed the data, including quality control. JRS provided statistical advice on study design and analyzed the data. RR and JRS drafted the article, and all authors contributed substantially to its revision. RR takes responsibility for the paper as a whole.

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Publication date: Available online August 18, 2011.

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