Comparison of Prehospital Vascular Access Strategies and Their Impact on Survival in Out-of-Hospital Cardiac Arrest

BackgroundOut-of-hospital cardiac arrest (OHCA) remains a critical emergency with low survival rates despite advanced prehospital interventions. Early epinephrine administration, particularly in non-shockable rhythms, improves outcomes. While intravenous (IV) access is the standard route for drug delivery, it is often difficult to obtain in the prehospital setting. Intraosseous (IO) access offers a viable alternative, but its comparative survival benefit remains unclear. Few studies have examined the impact of IO access on outcomes relative to patients who received no prehospital vascular access. This study aims to assess survival outcomes among OHCA patients receiving different prehospital vascular access strategies. Methods and ResultsThis retrospective cohort study included adult patients with non-traumatic OHCA in Taoyuan, Taiwan (June 2021-June 2024). Patients were categorized into four groups: IV, IO (humerus), failed IV, and no-access attempt. Primary outcomes were survival to discharge and favorable neurological status (CPC 1-2); secondary outcomes included prehospital ROSC and survival over 2 hours. Multivariable logistic regression adjusted for confounders. Among 4,424 patients, the IO group had the highest rates of ROSC (13.0%), 2-hour survival (28.0%), and discharge survival (16.6%), while the failed IV group had the lowest. IO access was associated with better outcomes than no-access attempt, with or without epinephrine. IO patients receiving epinephrine had the highest estimated survival and neurological outcomes. Each minute delay in epinephrine administration reduced survival odds by 4%. ConclusionsPrehospital vascular access--especially IO--was linked to improved OHCA survival and neurological outcomes. Prompt IO access should be considered when IV attempts fail. Clinical perspective What Is New?O_LIThis is the first study to comparing vascular access including IV, IO, IV fails and no access attempt before arriving hospital on non-traumatic OHCA patients. C_LIO_LIIn pre-hospital settings, IO access should be promptly established when IV fails, which significantly improving OHCA patient survival and neurological outcomes. C_LI What Are the Clinical Implications?O_LIThe study emphasizes the importance of establishing IO access while IV access failed on OHCA patients prior to hospital arrival in order to improve survival and neurological outcomes. C_LI