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January 3, 2025
Edited by Aaron Lacy
Yesterday we covered two RCTs (PARAMEDIC-3 and IVIO) that looked at outcomes in OHCA related to an IO vs IV first approach to access. Both studies found no difference in 30-day or neurologically intact survival.
No difference?
These articles came out in the context of another OHCA IO vs IV RCT (VICTOR) that also found no difference in similar outcomes. These results may impact your practice depending on your work environment, so we asked the experts for their opinion on how this recent literature boom may change their practice.
How will this change my practice? | Guest expert edition
Jason Lesnick, MD+ – View of the Emergency Department Physician
As a practicing EM physician, these studies will not significantly change my practice. My default approach in cardiac arrest patients for obtaining access is to communicate to the team we have two attempts at IV access, then to proceed to IO. These studies reaffirm my belief that prioritizing what we know works (shock early, minimal interruptions of quality compressions, effective ventilations, treat reversible pathology) is more important than type of access.
Kelly Tillotson, MD+ – View of the Clinician in the Field
One of the greatest struggles in prehospital medicine is obtaining venous access on patients. This is likely to continue with an aging population and increasing proportion of medically complex patients. Currently, the preference in some prehospital systems is IO access, due to perceived ease and speed. In my prehospital clinical system, initial attempts at venous access are IV, but after 2 or more failed attempts, IO access is pursued to prevent distraction from other more critical tasks, especially when available hands are limited.
After reviewing these studies in depth, they would not change my practice as a prehospital physician. For OHCA, I personally will choose an IO first so I can focus on the interventions shown to improve patient outcomes (e.g. high quality compressions, high compression fraction, brief peri-shock pauses, and addressing hypovolemic or obstructive shock in trauma). This is based on the unchanged outcome data and the limitations of the studies, which were well discussed by the authors.
However, real factors are worth noting, such as issues of enrollment power (less than half of what was calculated needed to determine 1% survivability in PARAMEDIC-3), and the variation of access sites (i.e. humoral vs tibial IO, central vs peripheral IV). These studies were also conducted in Europe, with different EMS systems, population health, and bystander CPR rates, among other factors, compared to the United States. Additionally, the noted average time to venous medication administration was > 20 minutes in PARAMEDIC-3, a late point in cardiac arrest resuscitation, at which survivability is universally poor. I think further research is needed on this topic to provide enough evidence for preferential adoption of either modality at this time.
James Li, MD+ – View of the EMS Medical Director
Currently, both the American Heart Association and European Resuscitation Council recommend IV attempts before IO for patients experiencing OHCA. Many EMS protocols reflect these recommendations. Both PARAMEDIC-3 and IVIO found no significant patient-centered outcomes regardless of which method of access was utilized. Time to access was similar for both IV and IO in both studies. I do not plan to make significant changes regarding vascular access to my cardiac arrest EMS protocols.
As an EMS medical director, these studies provide further evidence that EMS systems should prioritize aspects of OHCA care that lead to improved outcomes. Quality assurance and continuous quality improvement programs can provide valuable data for cardiac arrest care at EMS agencies. Training should focus on providing high-quality chest compressions, avoiding significant pauses in compressions, delivering appropriate ventilation rate and volume, defibrillating shockable rhythms early, and treating reversible etiologies of cardiac arrest.
Credentials+
- Jason Lesnick, MD is an Assistant Professor of Emergency Medicine and an Assistant Director of Undergraduate Medical Education at Vanderbilt University Medical Center, as well as being a fellow Spoon Feeder.
- Kelly Tillotson, MD is a Flight Physician for UC Health Air Care and serves as a Clinical Instructor of Emergency Medicine at the University of Cincinnati, SWAT physician, and assistant medical director for an urban and suburban fire department. She is the current EMS fellow at the University of Cincinnati.
- James Li MD, MEd, FAEMS is an Assistant Professor of Emergency Medicine and the Associate Program Director for the EMS Fellowship at Washington University School of Medicine in St Louis. He is the medical director for multiple EMS agencies in the St. Louis region and believes high quality EMS education translates into high quality patient care.
