Key PointsQuestion  Is an intraosseous vs intravenous route for epinephrine administration associated with a difference in survival to hospital discharge among pediatric patients with out-of-hospital cardiac arrest?

Findings  In this cohort study of 739 children with out-of-hospital cardiac arrest using propensity scores and inverse probability of treatment weighting, there was no association between the route of epinephrine administration and survival to hospital discharge.

Meaning  These findings may support a practice of administering epinephrine via either an intraosseous or intravenous route for pediatric patients with out-of-hospital cardiac arrest.

Abstract                   

Importance  While epinephrine is commonly administered in children with out-of-hospital cardiac arrest (OHCA) via an intraosseous (IO) or intravenous (IV) route, the optimal route of epinephrine delivery is unclear.

Objective  To evaluate the association between the route of epinephrine administration (IO or IV) and patient outcomes after pediatric OHCA.

Design, Setting, and Participants  Retrospective cohort study of pediatric patients (aged <18 years) with nontraumatic OHCA treated by emergency medical services who received prehospital epinephrine either via an IO or IV route. Patients were included in the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective OHCA registry at 10 sites in the US and Canada from April 2011 to June 2015. Data analysis was performed from May 2024 to April 2025.

Exposure  Epinephrine administration route: IO or IV route.

Main Outcomes and Measures  The primary outcome was survival to hospital discharge. The secondary outcome was return of spontaneous circulation (ROSC) before hospital arrival. Propensity scores were calculated and inverse probability of treatment weighting (IPTW) was performed with stabilized weights to control imbalances in measured patient demographics, cardiac arrest characteristics, and bystander and prehospital interventions.

Results  Of 739 eligible patients (median [IQR] age, 1 [0-11] years), 449 (60.8%) were male. Epinephrine was administered via an IO route for 535 (72.4%) and via an IV route for 204 (27.6%) patients. In the IPTW pseudopopulation (740 weighted cases), there was no significant difference in survival to hospital discharge (IO epinephrine: 28 of 528 patients [5.3%] vs IV epinephrine: 12 of 212 patients [5.7%]; risk ratio [RR], 0.92; 95% CI, 0.41-2.07) or prehospital ROSC (IO epinephrine: 76 of 528 patients [14.4%] vs IV epinephrine: 46 of 212 patients [21.7%]; RR, 0.66; 95% CI, 0.42-1.03) between the IO and IV epinephrine groups.

Conclusions and Relevance  In this retrospective cohort study of pediatric patients with OHCA in the US and Canada, the route of epinephrine administration was not associated with survival to hospital discharge or prehospital ROSC. This may support the practice of administering epinephrine via IO or IV route.