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. 2025 Jun 2;8(6):e2517291.
doi: 10.1001/jamanetworkopen.2025.17291.

Intraosseous vs Intravenous Access for Epinephrine in Pediatric Out-of-Hospital Cardiac Arrest

Masashi Okubo  1 , Sho Komukai  2 , Junichi Izawa  3   4 , SunHee Chung  5 , Cameron Dezfulian  6 , Francis X Guyette  1 , Joshua R Lupton  5 , Christian Martin-Gill  1 , Sylvia Owusu-Ansah  7 , Sriram Ramgopal  8 , Clifton W Callaway  1
Affiliations

Intraosseous vs Intravenous Access for Epinephrine in Pediatric Out-of-Hospital Cardiac Arrest

Masashi Okubo et al. JAMA Netw Open. .

Abstract

Importance: While epinephrine is commonly administered in children with out-of-hospital cardiac arrest (OHCA) via an intraosseous (IO) or intravenous (IV) route, the optimal route of epinephrine delivery is unclear.

Objective: To evaluate the association between the route of epinephrine administration (IO or IV) and patient outcomes after pediatric OHCA.

Design, setting, and participants: Retrospective cohort study of pediatric patients (aged <18 years) with nontraumatic OHCA treated by emergency medical services who received prehospital epinephrine either via an IO or IV route. Patients were included in the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective OHCA registry at 10 sites in the US and Canada from April 2011 to June 2015. Data analysis was performed from May 2024 to April 2025.

Exposure: Epinephrine administration route: IO or IV route.

Main outcomes and measures: The primary outcome was survival to hospital discharge. The secondary outcome was return of spontaneous circulation (ROSC) before hospital arrival. Propensity scores were calculated and inverse probability of treatment weighting (IPTW) was performed with stabilized weights to control imbalances in measured patient demographics, cardiac arrest characteristics, and bystander and prehospital interventions.

Results: Of 739 eligible patients (median [IQR] age, 1 [0-11] years), 449 (60.8%) were male. Epinephrine was administered via an IO route for 535 (72.4%) and via an IV route for 204 (27.6%) patients. In the IPTW pseudopopulation (740 weighted cases), there was no significant difference in survival to hospital discharge (IO epinephrine: 28 of 528 patients [5.3%] vs IV epinephrine: 12 of 212 patients [5.7%]; risk ratio [RR], 0.92; 95% CI, 0.41-2.07) or prehospital ROSC (IO epinephrine: 76 of 528 patients [14.4%] vs IV epinephrine: 46 of 212 patients [21.7%]; RR, 0.66; 95% CI, 0.42-1.03) between the IO and IV epinephrine groups.

Conclusions and relevance: In this retrospective cohort study of pediatric patients with OHCA in the US and Canada, the route of epinephrine administration was not associated with survival to hospital discharge or prehospital ROSC. This may support the practice of administering epinephrine via IO or IV route.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Owusu-Ansah reported being a consultant for Prodigy EMS outside the submitted work. Dr Ramgopal reported receiving grants from the Gerber Foundation, the Pediatric Pandemic Network, and the National Heart, Lung and Blood Institute outside the submitted work. Dr Callaway reported receiving grants from the National Institutes of Health (NIH), the American Heart Association, and the Society for Academic Emergency Medicine during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flow
EMS indicates emergency medical services; IO, intraosseous; IV, intravenous; OHCA, out-of-hospital cardiac arrest; ROSC, return of spontaneous circulation.
Figure 2.
Figure 2.. Cumulative Proportion of Patients Without Return of Spontaneous Circulation (ROSC) Over Time From Epinephrine Administration and Advanced Life Clinician Arrival in the Weighted Population, Stratified by the Route of Epinephrine Administration
A, Log-rank P = .29. The hazard ratio for the IO group was 0.71 (95% CI, 0.43-1.20). B, Log-rank P = .41. The hazard ratio for the IO group was 0.77 (95% CI, 0.47-1.28). IO indicates intraosseous; IV, intravenous.
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