Hubble Michael W, Martin Melisa D, Kaplan Ginny R, Houston Sara E, Taylor Stephen E
Department of Emergency Medical Science, Wake Technical Community College, Wendell, North Carolina.
Department of Health Care Administration & Advanced Paramedicine, Methodist University, Fayetteville, North Carolina.
Prehosp Emerg Care. 2025;29(6):826-834. doi: 10.1080/10903127.2024.2414389. Epub 2024 Oct 14.
Previous investigations comparing intraosseous (IO) and intravenous (IV) epinephrine delivery in out-of-hospital cardiac arrest (OHCA) suggest that epinephrine is oftentimes more expeditiously administered the IO route, but this temporal benefit doesn't always translate to clinical benefit. However, very few studies adequately controlled for indication and resuscitation time biases, making the influence of first epinephrine route on OHCA outcomes unclear. To determine the association between first epinephrine route and return of spontaneous circulation (ROSC) while controlling for resuscitation time bias and other potential confounders.
We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. Adult patients with a witnessed, non-traumatic OHCA prior to EMS arrival were included. Logistic regression was used to determine the association between medication route and ROSC. Linear regression was then used to calculate the probability of ROSC for each route across all call receipt-to-drug delivery intervals. Using these linear equations, the call receipt-to-drug delivery intervals were calculated that would yield equivalent probabilities of ROSC between the IV and IO routes.
Data were available for 10,350 patients, of which 27.4% presented with a shockable rhythm, 29.7% received bystander CPR, and 39.6% experienced ROSC. After controlling for confounders, IO epinephrine was associated with decreased likelihood of ROSC (OR = 0.77, < 0.001). The linear regression models provided differing slope coefficients for ROSC between each route, with the IV route associated with a higher likelihood of ROSC for any given call receipt-to-drug-delivery interval. From these equations, the additional time allowed to establish an IV and administer epinephrine intravenously beyond the time required for IO delivery, yet with an equivalent predicted probability of ROSC the IO route, was calculated. This additional time interval for intravenous administration declined linearly from 9 min at a call receipt-to-intraosseous epinephrine interval of 4 min to no additional time at a call receipt-to-intraosseous epinephrine interval of 29 min.
This retrospective analysis of a national EMS database revealed that IO epinephrine was negatively associated with ROSC. Additionally, there appears to be a finite time window during which intravenous epinephrine remains superior to the intraosseous route even if there are brief initial delays in IV drug delivery.
先前比较院外心脏骤停（OHCA）时骨内（IO）和静脉（IV）注射肾上腺素的研究表明，肾上腺素通常通过IO途径给药更快，但这种时间上的优势并不总是转化为临床益处。然而，很少有研究充分控制适应症和复苏时间偏差，使得首次肾上腺素给药途径对OHCA结局的影响尚不清楚。为了确定首次肾上腺素给药途径与自主循环恢复（ROSC）之间的关联，同时控制复苏时间偏差和其他潜在混杂因素。
我们使用2020年ESO数据协作数据集进行了一项回顾性分析。纳入了在急救医疗服务（EMS）到达之前发生目击、非创伤性OHCA的成年患者。使用逻辑回归来确定给药途径与ROSC之间的关联。然后使用线性回归来计算在所有呼叫接收至药物给药间隔内每种途径的ROSC概率。使用这些线性方程，计算出在IV和IO途径之间产生等效ROSC概率的呼叫接收至药物给药间隔。
有10350名患者的数据可用，其中27.4%表现为可电击心律，29.7%接受了旁观者心肺复苏（CPR），39.6%实现了ROSC。在控制混杂因素后，IO注射肾上腺素与ROSC可能性降低相关（OR = 0.77，P < 0.001）。线性回归模型为每种途径的ROSC提供了不同的斜率系数，对于任何给定的呼叫接收至药物给药间隔，IV途径与更高的ROSC可能性相关。根据这些方程，计算出在建立IV并静脉注射肾上腺素所需时间之外，还允许的额外时间，同时具有与IO途径等效的预测ROSC概率。静脉给药的这个额外时间间隔从呼叫接收至骨内注射肾上腺素间隔为4分钟时的9分钟线性下降到呼叫接收至骨内注射肾上腺素间隔为29分钟时无额外时间。
对国家EMS数据库的这项回顾性分析表明，IO注射肾上腺素与ROSC呈负相关。此外，似乎存在一个有限的时间窗口，在此期间静脉注射肾上腺素即使在IV药物给药存在短暂初始延迟的情况下仍优于骨内途径。
