Two recent studies (see “Additional Information” for more study details) published in the New England Journal of Medicine evaluated the outcomes of OHCA, comparing drug administration via intraosseous devices versus intravenous access, neither demonstrating benefit to one strategy over the other in terms of sustained ROSC or 30-day survival. [1,2] While there were a few limitations, these results are generally in line with existing literature. Although it is worth noting that some studies signal improved outcomes with IV access, the time to intervention seems to be the more important metric related to outcome. [3-5]

Bottom Line: Intraosseous devices remain rapid and easy to place devices that can provide access for drug administration when IV access is unable to be obtained. In patients with difficult access, use an IO to administer meds, fluids, or blood products as indicated while you and your team work on more definitive IV access and focus on high-quality CPR.

Additional Information

Couper et al.

• Multicenter, pragmantic, open-label, RCT in 11 EMS systems in the UK
• 3040 IO first, 3042 IV first
• Mostly men (64%), mean age 68y
• Primary outcome=30 day survival
  • No difference between groups (4.5% IO vs. 5.1% IV)
• Secondary outcomes
  • Favorable neuro outcome at hospital discharge – no difference between groups (2.7 % IO vs. 2.8 % IV)
  • ROSC at any time - slightly better in IV group (35% IO vs. 39% IV - adjusted odds ratio, 0.86; 95% CI, 0.76 to 0.97)
  • Same median time-to-drug-administration in both groups (24 min)
• Study terminated early due to low enrollment, and no info on quality of resus or post-ROSC care

Vallentin et al. 

• Multicenter, randomized, parallel-group in Denmark
• 731 IO first, 748 IV first
• Mostly men (70%), mean age 69y
• Primary outcome= sustained ROSC
  • No difference between groups (30% IO vs. 29% IV)
• Secondary outcomes
  • 30 day survival - no difference between groups (12% IO vs. 10% IV)
  • 30 day survival with favorable neuro outcome
• Trial not actually powered for longer term outcomes, non-blinded, some group crossover

References

1. Couper K, Ji C, Deakin CD, et al; PARAMEDIC-3 Collaborators. A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2025 Jan 23;392(4):336-348. doi: 10.1056/NEJMoa2407780
2. Vallentin MF, Granfeldt A, Klitgaard TL, et al. Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med. 2025 Jan 23;392(4):349-360. doi: 10.1056/NEJMoa2407616
3. Lee AF, Chang YH, Chien LT, et al. A comparison between intraosseous and intravenous access in patients with out-of-hospital cardiac arrest: A retrospective cohort study. Am J Emerg Med. 2024 Jun;80:162-167. doi: 10.1016/j.ajem.2024.04.009
4. Granfeldt A, Avis SR, Lind PC, et al. Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review. Resuscitation. 2020 Apr;149:150-157. doi: 10.1016/j.resuscitation.2020.02.025
5. Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2017 Aug;117:91-96. doi: 10.1016/j.resuscitation.2017.06.014