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Original Research

Open Access Special Issue

Effect of prehospital intraosseous combined with in-hospital intravenous access in out-of-hospital cardiac arrest

  • Yan-Wei Cheng1,†
  • Jian-Ge Zhang1,†
  • Xue Cao2
  • Juan Zhu1
  • Li-Jie Qin1

1Department of Emergency, Henan Provincial People′s Hospital, People′s Hospital of Zhengzhou University, People′s Hospital of Henan University, 450000 Zhengzhou, P. R. China

2Department of Rheumatology and Immunology, Henan Provincial People′s Hospital, People′s Hospital of Zhengzhou University, People′s Hospital of Henan University, 450000 Zhengzhou, P. R. China

DOI: 10.22514/sv.2021.046 Vol.17,Issue 6,November 2021 pp.125-130

Submitted: 26 January 2021 Accepted: 20 February 2021

Published: 08 November 2021

(This article belongs to the Special Issue Efficacy of Medication Administered During Adult Cardiac Arrest)

*Corresponding Author(s): Li-Jie Qin E-mail:

† These authors contributed equally.


Objective: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to compare the effectiveness of prehospital intraosseous infusion (IO) combined with in-hospital intravenous (IV) (pre-IO + in-IV) access versus the simple IV (pre-IV + in-IV) access in adult OHCA patients who do not achieve prehospital return of spontaneous circulation (ROSC).

Methods: This retrospective observational study included adults with OHCA of presumed cardiac etiology between October 1, 2017-October 1, 2020 at an academic emergency department in China. All of the OHCA patients included within the study had Emergency Medical Services cardiopulmonary resuscitation and received prehospital epinephrine administration, but did not achieve prehospital ROSC. The study population were classified as either pre-IO + in-IV or IV (pre-IV + in-IV) based on their epinephrine administration route. The prehospital epinephrine routes were the first and only attempted route. The primary outcome investigated was sustained ROSC following arrival at the emergency department. The secondary outcome considered was the time from dispatch to the first epinephrine dose.

Results: Of 193 included adult OHCA subjects who did not have prehospital ROSC, 128 received IV access only. The 65 pre-IO + in-IV-treated patients received epinephrine faster compared to IV-treated patients in terms of the median time from dispatch to the first injection of epinephrine (14.5 vs. 16.0 min, P = 0.001). In the pre-IO + in-IV group, 34 of 65 patients (52.3%) achieved sustained ROSC compared with 65 of 128 (50.8%) patients in the IV group (χ2 = 0.031, P = 0.841). There was no significant difference in sustained ROSC (adjusted OR1.049, 95% CI: 0.425-2.591, P = 0.918) between the two groups.

Conclusion: A similar sustained ROSC rate was achieved for both the pre-IO + in-IV access group and the simple IV access group. Our results suggested that an IV route should be established quickly for prehospital IO-treated OHCA patients who do not achieve prehospital ROSC.


Out-of-hospital cardiac arrest; Intraosseous; Intravenous; Epinephrine; Return of spontaneous circulation

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Yan-Wei Cheng,Jian-Ge Zhang,Xue Cao,Juan Zhu,Li-Jie Qin. Effect of prehospital intraosseous combined with in-hospital intravenous access in out-of-hospital cardiac arrest. Signa Vitae. 2021. 17(6);125-130.


[1] Myat A, Song K, Rea T. Out-of-hospital cardiac arrest: current concepts. The Lancet. 2018; 391: 970-979.

[2] Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020; 141: e139-e596.

[3] Hansen M, Schmicker RH, Newgard CD, Grunau B, Scheuermeyer F, Cheskes S, et al. Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults. Circulation. 2018; 137: 2032-2040.

[4] Botnaru T, Dankoff J. Epinephrine compared to placebo in cardiac arrest resuscitation. Canadian Journal of Emergency Medicine. 2015; 16: 151-154.

[5] Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. New England Journal of Medicine. 2018; 379: 711-721.

[6] Reades R, Studnek JR, Vandeventer S, Garrett J. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial. Annals of Emergency Medicine. 2011; 58: 509- 516.

[7] Hoskins SL, do Nascimento P, Lima RM, Espana-Tenorio JM, Kramer GC. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation. 2012; 83: 107-112.

[8] Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2017; 117: 91-96.

[9] Kawano T, Grunau B, Scheuermeyer FX, Gibo K, Fordyce CB, Lin S, et al. Intraosseous vascular access is associated with lower survival and neurologic recovery among patients with out-of-hospital cardiac arrest. Annals of Emergency Medicine. 2018; 71: 588-596.

[10] Clemency B, Tanaka K, May P, Innes J, Zagroba S, Blaszak J, et al. Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest. The American Journal of Emergency Medicine. 2017; 35: 222-226.

[11] Nguyen L, Suarez S, Daniels J, Sanchez C, Landry K, Redfield C. Effect of intravenous versus intraosseous access in prehospital cardiac arrest. Air Medical Journal. 2019; 38: 147-149.

[12] Mody P, Brown SP, Kudenchuk PJ, Chan PS, Khera R, Ayers C, et al. Intraosseous versus intravenous access in patients with out-of hospital cardiac arrest: Insights from the resuscitation outcomes consortium continuous chest compression trial. Resuscitation. 2019; 134: 69-75.

[13] Zhang Y, Zhu J, Liu Z, Gu L, Zhang W, Zhan H, et al. Intravenous versus intraosseous adrenaline administration in out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation. 2020; 149: 209-216.

[14] Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142: S366-S468.

[15] Kudenchuk PJ, Daya M, Dorian P; Resuscitation Outcomes Consortium Investigators. Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest. The New England Journal of Medicine. 2016; 375: 802-803.

[16] Nolan JP, Deakin CD, Ji C, Gates S, Rosser A, Lall R, et al. Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial. Intensive Care Medicine. 2020; 46: 954-962.

[17] Ross EM, Mapp J, Kharod C, Wampler DA, Velasquez C, Miramontes DA. Time to epinephrine in out-of-hospital cardiac arrest: a retrospective analysis of intraosseous versus intravenous access. American Journal of Disaster Medicine. 2016; 11: 119-123.

[18] Von Hoff DD, Kuhn JG, Burris HA 3rd, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. American Journal of Emergency Medicine. 2008; 26: 31-38.

[19] Wong MR, Reggio MJ, Morocho FR, Holloway MM, Garcia-Blanco JC, Jenkins C, et al. Effects of intraosseous epinephrine in a cardiac arrest swine model. Journal of Surgical Research. 2016; 201: 327-333.

[20] Voelckel WG, Lurie KG, McKnite S, Zielinski T, Lindstrom P, Peterson C, et al. Comparison of epinephrine with vasopressin on bone marrow blood flow in an animal model of hypovolemic shock and subsequent cardiac arrest. Critical Care Medicine. 2001; 29: 1587-1592.

[21] Delguercio LR, Coomaraswamy RP, State D. Cardiac output and other hemodynamic variables during external cardiac massage in man. The New England Journal of Medicine. 1963; 269: 1398-1404.

[22] Morgan RW, Berg RA. Intraosseous adrenaline for adult out-of-hospital cardiac arrest: faster access with worse outcomes. Resuscitation. 2020; 149: 238-239.

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