Boon Kiat Kenneth Tan1, Yun Xin Chin2, Zhi Xiong Koh1, Nur Ain Zafirah Bte Md Said3, Masnita Rahmat3, Stephanie Fook-Chong4, Yih Yng Ng5, Marcus Eng Hock Ong6. 1. Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore. 2. Department of Anaesthesiology, Singapore General Hospital, Outram Road, 169608, Singapore. 3. Medical Department, Singapore Civil Defence Force, 91 Ubi Avenue 4, 408827, Singapore. 4. Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore. 5. Home Team Medical Services Division, Ministry of Home Affairs, 28 Irrawaddy Road, 329560, Singapore; Emergency Department, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore. 6. Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore; Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore. Electronic address: marcus.ong.e.h@singhealth.com.sg.
Abstract
OBJECTIVE: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to determine if using intraosseous (IO) access when intravenous (IV) access fails improves outcomes. METHODS: This was a prospective, parallel-group, cluster-randomised study that compared 'IV only' against 'IV + IO' in OHCA patients, where if 2 IV attempts failed or took more than 90 s, paramedics had 2 further attempts of IO. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were insertion success rate, adrenaline administration, time to adrenaline and survival outcome. RESULTS:A total of 1007 patients were included in the analysis. An Intention To Treat analysis showed a significant difference in success rates of obtaining vascular access in the IV + IO arm compared to the IV arm (76.6% vs 61.1% p = 0.001). There were significantly more patients in the IV + IO arm than the IV arm being administered prehospital adrenaline (71.3% vs 55.4% p = 0.001). The IV + IO arm also received adrenaline faster compared to the IV arm in terms of median time from emergency call to adrenaline (23 min vs 25 min p = 0.001). There was no significant difference in ROSC (adjusted OR 0.99 95%CI: 0.75-1.29), survival to discharge or survival with CPC 2 or better in both groups. A Per Protocol analysis also showed there was higher success in obtaining vascular access in the IV + IO arm, but ROSC and survival outcomes were not statistically different. CONCLUSION: Using IO when IV failed led to a higher rate of vascular access, prehospital adrenaline administration and faster adrenaline administration. However, it was not associated with higher ROSC, survival to discharge, or good neurological outcome.
RCT Entities:
OBJECTIVE: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to determine if using intraosseous (IO) access when intravenous (IV) access fails improves outcomes. METHODS: This was a prospective, parallel-group, cluster-randomised study that compared 'IV only' against 'IV + IO' in OHCA patients, where if 2 IV attempts failed or took more than 90 s, paramedics had 2 further attempts of IO. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were insertion success rate, adrenaline administration, time to adrenaline and survival outcome. RESULTS: A total of 1007 patients were included in the analysis. An Intention To Treat analysis showed a significant difference in success rates of obtaining vascular access in the IV + IO arm compared to the IV arm (76.6% vs 61.1% p = 0.001). There were significantly more patients in the IV + IO arm than the IV arm being administered prehospital adrenaline (71.3% vs 55.4% p = 0.001). The IV + IO arm also received adrenaline faster compared to the IV arm in terms of median time from emergency call to adrenaline (23 min vs 25 min p = 0.001). There was no significant difference in ROSC (adjusted OR 0.99 95%CI: 0.75-1.29), survival to discharge or survival with CPC 2 or better in both groups. A Per Protocol analysis also showed there was higher success in obtaining vascular access in the IV + IO arm, but ROSC and survival outcomes were not statistically different. CONCLUSION: Using IO when IV failed led to a higher rate of vascular access, prehospital adrenaline administration and faster adrenaline administration. However, it was not associated with higher ROSC, survival to discharge, or good neurological outcome.
Authors: Travis W Murphy; Scott A Cohen; Charles W Hwang; K Leslie Avery; Meenakshi P Balakrishnan; Ramani Balu; Muhammad Abdul Baker Chowdhury; David B Crabb; Yasmeen Elmelige; Carolina B Maciel; Sarah S Gul; Francis Han; Torben K Becker Journal: J Am Coll Emerg Physicians Open Date: 2022-07-14