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Smida T, Crowe R, Jarvis J, Ratcliff T, Goebel M. Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation. PREHOSP EMERG CARE 2024; 28:779-786. [PMID: 38416867 DOI: 10.1080/10903127.2024.2321285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation. METHODS The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access. RESULTS After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access. CONCLUSION In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.
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Affiliation(s)
- Tanner Smida
- West Virginia University MD/PhD Program, Morgantown, West Virginia
| | | | - Jeffrey Jarvis
- Metropolitan Area EMS Authority, Fort Worth, Texas
- Department of Emergency Medicine, Texas A&M College of Medicine, Bryan, Texas
| | - Taylor Ratcliff
- Department of Emergency Medicine, Texas A&M College of Medicine, Bryan, Texas
| | - Mat Goebel
- University of Massachusetts Chan Medical School - Baystate, Springfield, Massachusetts
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Couper K, Ji C, Lall R, Deakin CD, Fothergill R, Long J, Mason J, Michelet F, Nolan JP, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Walker A, Chowdhury L, Norman C, Sprauve L, Starr K, Wood S, Bell S, Bradley G, Brown M, Brown S, Charlton K, Coppola A, Evans C, Evans C, Foster T, Jackson M, Kearney J, Lang N, Mellett-Smith A, Osborne R, Pocock H, Rees N, Spaight R, Tibbetts B, Whitley GA, Wiles J, Williams J, Wright A, Perkins GD. Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3). Resusc Plus 2024; 17:100544. [PMID: 38260121 PMCID: PMC10801302 DOI: 10.1016/j.resplu.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
Aims The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest. Methods PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained. Conclusion The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.
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Affiliation(s)
- Keith Couper
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chen Ji
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Rachael Fothergill
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - John Long
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Felix Michelet
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Henry Nwankwo
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael A Smyth
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Alison Walker
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
- Emergency Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | | | - Chloe Norman
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Kath Starr
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Sara Wood
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Steve Bell
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gemma Bradley
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Martina Brown
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Shona Brown
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison Coppola
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | | | - Christine Evans
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Michelle Jackson
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Justin Kearney
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | | | - Adam Mellett-Smith
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - Ria Osborne
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Helen Pocock
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Cwmbran, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | | | | | - Jason Wiles
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Julia Williams
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
- Department of Paramedic Science, University of Hertfordshire, Hatfield, UK
| | - Adam Wright
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gavin D Perkins
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Brebner C, Asamoah-Boaheng M, Zaidel B, Yap J, Scheuermeyer F, Mok V, Christian M, Kawano T, Singh L, van Diepen S, Christenson J, Grunau B. The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests. Resuscitation 2023; 193:110031. [PMID: 37923113 DOI: 10.1016/j.resuscitation.2023.110031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
AIM Humeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes. METHODS We used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1-2) and survival at hospital discharge. RESULTS We included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4-9.4) and 6.1 minutes (IQR 4.1-8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90-2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83-2.01). Results using the full cohort were similar. CONCLUSIONS We did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.
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Affiliation(s)
- Callahan Brebner
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Asamoah-Boaheng
- Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Bianca Zaidel
- Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Justin Yap
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Frank Scheuermeyer
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Valerie Mok
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Christian
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Division of Critical Care Medicine, University of British Columbia, British Columbia, Canada; British Columbia Emergency Health Services, British Columbia, Canada
| | - Takahisa Kawano
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Lovepreet Singh
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Sean van Diepen
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jim Christenson
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Brian Grunau
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada; British Columbia Emergency Health Services, British Columbia, Canada.
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