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IV or IO Antiarrhythmics for OHCA?

March 12, 2020

Written by Rick Ramirez and Clay Smith

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For patients with out-of-hospital cardiac arrest (OHCA), both amiodarone and lidocaine (in comparison with placebo) were associated with improved survival to hospital discharge when given via the IV route compared with IO.

Why does this matter?
Obtaining reliable IV access for OHCA can be difficult depending on the patient and the situation. The American Heart Association notes that when IV access is unobtainable, an IO should be attempted and medications given via this route. However, comparing IV vs IO antiarrhythmic medication administration for patient survival and intact neurological status rates has not been previously studied.

IV seems to beat IO…
This prespecified analysis of the ROC-ALPS trial compared the differences in IV or IO route on survival-to-hospital-discharge in adults with OHCA due to shock-refractory v-fib/pulseless v-tach who were randomly assigned by EMS personnel to either amiodarone or lidocaine versus placebo.

Of 3,019 randomly assigned patients with a known vascular access site, 2,358 received ALPS drugs IV and 661 patients by the IO route. Overall, hospital discharge survival rates were 23%. In comparison with placebo, discharge survival was significantly higher in recipients of IV amiodarone, aRR 1.26 (95%CI 1.06 to 1.50); and IV lidocaine, aRR 1.21 (95%CI 1.02 to 1.45). However, discharge survival was unchanged in recipients of IO amiodarone, aRR 0.94 (95%CI 0.66 to 1.32); or IO lidocaine aRR 1.03 (95%CI 0.74 to 1.44). Survival with improved neurological outcome at discharge was an interesting and hypothesis-generating secondary outcome, with IV amiodarone showing a statistically significant improvement over placebo, aRR 1.24 (95%CI 1.02 to 1.52); and IV lidocaine nearly reaching significance, aRR 1.17 (95%CI 0.95 to 1.44). There was no statistical difference when looking only at vascular access route, IV vs IO, and survival after any study drug (amiodarone, lidocaine, or placebo); p=0.32 for the IV to IO interaction.

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation. 2020 Jan 21;141(3):188-198. doi: 10.1161/CIRCULATIONAHA.119.042240. Epub 2020 Jan 16.

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