Intraosseous Versus Intravenous Vascular Access During Cardiac Arrest
The objective of this study will be to compare humeral and tibial IO needle insertions to peripheral IV access during cardiac arrest.
Hypothesis There is a difference in first attempt success of tibial IOs compared to humeral IOs or peripheral IV among cardiac arrest patients.
Methods This will be a randomized controlled trial conducted within Mecklenburg County by the Mecklenburg County EMS Agency (MEDIC). The study population includes all adult (greater than 18 years of age) cardiac arrest patients of a medical etiology upon whom resuscitative efforts are initiated.
Patient Care Protocols Prehospital protocols for adult cardiac arrest patients within Mecklenburg County state that all first responders follow advanced cardiac life support (ACLS) algorithms during cardiopulmonary resuscitation. Current MEDIC protocols specify that initial vascular access be obtained by paramedics via either tibial or humeral IO needle insertion, followed by peripheral IV for secondary access. This study will randomize initial vascular access to a humeral IO, tibial IO, or peripheral IV.
Once paramedics arrive on-scene, they will take a pack from the ambulance containing all necessary supplies to begin resuscitation. These packs are already present on each ambulance in Mecklenburg County and contain an EZ-IO drill, IO needles, ACLS medications, and KING LTD airway device. For the purposes of this study, peripheral IV start kits will be added to these resuscitation packs at the start of study implementation.
150 note cards will be prepared in advance and labeled with a vascular access method. [50 cards with "Tibial IO", 50 cards "Humeral IO", 50 cards with "Peripheral IV"] Each note card will be sealed in a blank, numbered envelope. A master list will be prepared in advance according to envelope number indicating which vascular access method was placed in each numbered envelope. This list will only be available to the MEDIC Quality Assurance/Quality Improvement (QA/QI) personnel responsible for paramedic debriefing and recirculation of unused envelopes.
Sealed envelopes will then be shuffled and placed at the MEDIC circulation window where resuscitation packs and ambulance equipment are distributed daily.
Each crew will randomly select and open an envelope prior to every shift. By opening the envelope at the start of the day, this will eliminate the possibility of envelopes being left in the ambulance unit or lost at the scene, as well as prevent delays with patient care.
The envelope number will be recorded at the circulation window indicating the specific MEDIC ambulance unit and assigned crew.
The vascular access route selected will apply to the crew's first cardiac arrest of the day.
Paramedics will conduct the resuscitation according to existing procedure, and will proceed with vascular access as follows depending on the method selected by randomization:
Tibial IO First attempt will be a tibial IO. Second attempt should occur on the opposite tibia if the first IO fails. Subsequent attempts will be for a humeral IO or peripheral IV as selected by the paramedic.
Humeral IO First attempt will be a humeral IO. Second attempt should occur at the tibia if the first humeral IO fails. Subsequent attempts will be for a peripheral IV or additional IOs as determined by the paramedic.
Peripheral IV First attempt will be a peripheral IV in the AC. If this fails, second attempt will be a tibial IO, followed by a humeral IO when indicated.
Since it is extremely rare for any crew to conduct more than one cardiac arrest on a given day, the randomized vascular access method will only apply to the first cardiac arrest of the day. As crews do not return to the distribution center until the end of a shift (12 hours), it will be impossible to select additional envelopes for subsequent patient encounters. Paramedics will proceed with vascular access per current MEDIC prehospital protocols for any further cardiac arrest resuscitations that day.
If there is a contraindication to the vascular access site selected such as extremity amputations, orthopedic hardware, skin infection, or traumatic injuries, paramedics will proceed to the next insertion site as per the above protocol. For instance, if a patient with bilateral lower extremity amputations is randomized to a tibial IO insertion site, paramedics will classify this as a failed attempt and proceed to humeral IO, then peripheral IV as stated above. For patients with isolated skin infections or orthopedic hardware involving one extremity, paramedics will select the unaffected extremity for the first attempt. Any unforeseen circumstances will be addressed according to the paramedics' discretion and reported to the primary investigator immediately. Such occurrences will be included in the final data analysis for this study.
|Cardiac Arrest||Device: Intravenous access during OHCA Device: Humeral IO insertion Device: TIbial IO insertion|
|Study Design:||Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
|Official Title:||Intraosseous Versus Intravenous Vascular Access During Cardiac Arrest|
- First attempt success rate between the tibial IO, humeral IO, and peripheral IV. [ Time Frame: 1 day ]This measure will be assessed on the day an individual experiences cardiac arrest and will not be followed upon admission to the emergency department.
- Time to first ACLS medication [ Time Frame: 1 day ]This measure will be assessed on the day an individual experiences cardiac arrest and will not be followed upon admission to the emergency department.
- Time to vascular access [ Time Frame: 1 day ]This measure will be assessed on the day an individual experiences cardiac arrest and will not be followed upon admission to the emergency department.
- Fluid flow rates as measured by total volume infused during resuscitation. [ Time Frame: 1 day ]
|Study Start Date:||May 2010|
|Study Completion Date:||October 2010|
|Primary Completion Date:||October 2010 (Final data collection date for primary outcome measure)|
Device: Intravenous access during OHCA
First attempt will be a peripheral IV in the AC. If this fails, second attempt will be a tibial IO, followed by a humeral IO when indicated.
|Experimental: Humeral IO||
Device: Humeral IO insertion
First attempt will be a humeral IO. Second attempt should occur at the tibia if the first humeral IO fails. Subsequent attempts will be for a peripheral IV or additional IOs as determined by the paramedic.
|Active Comparator: Tibial IO||
Device: TIbial IO insertion
First attempt will be a tibial IO. Second attempt should occur on the opposite tibia if the first IO fails. Subsequent attempts will be for a humeral IO or peripheral IV as selected by the paramedic.
Please refer to this study by its ClinicalTrials.gov identifier: NCT01119807
|United States, North Carolina|
|Mecklenburg EMS Agency|
|Charlotte, North Carolina, United States|