Prehospital Vascular Access Guidelines

Primary Recommendation

The American Heart Association recommends attempting intravenous (IV) access first for drug administration during adult cardiac arrest, with intraosseous (IO) access reserved as a backup when IV access fails or cannot be obtained, for both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) settings 1, 2, 3, 4, 5

The International Consensus on Cardiopulmonary Resuscitation provides evidence that IV access is associated with better survival to hospital discharge, with 20 more survivors per 1,000 cardiac arrests compared to IO access (adjusted OR 0.71, 95% CI 0.63-0.79) 3, 4
IV access is associated with better survival with favorable neurological outcome, with 19 more survivors with good neurological outcomes per 1,000 cardiac arrests (adjusted OR 0.60, 95% CI 0.52-0.69) 1, 3, 6
IV access is associated with a higher return of spontaneous circulation (ROSC) rate, with 61 more patients achieving ROSC per 1,000 cardiac arrests (adjusted OR 0.72, 95% CI 0.68-0.76) 1, 7, 8

The certainty of evidence is very low due to risk of bias and inconsistency in observational studies 1, 2, 3
The American Heart Association acknowledges that patients who received IO access may have had worse baseline characteristics that contributed to poorer outcomes 10, 6
IO access should be used immediately without delay if initial IV access attempts are unsuccessful, or if IV access is not feasible due to patient factors (severe hypovolemia, shock, obesity, IV drug use) 3, 4, 5, 7

Attempt peripheral IV access first in all patients requiring vascular access during resuscitation 1, 3, 10
Switch to IO access immediately if peripheral IV cannot be obtained within 1-2 attempts, or if patient is in profound shock making IV access unlikely to succeed 3, 4, 7
Consider IO as first-line for severe trauma patients with hemorrhagic shock, patients requiring multiple simultaneous life-saving interventions, or in mass casualty or austere environments where time is critical 3, 4

Tibial insertion is most commonly documented, though humeral sites may also be used, with no evidence to recommend one IO site over another 4, 10