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Tibial intraosseous (TIO) access may be a faster alternative to intravenous (IV) access for delivery of vasoactive medications” Wong et al (2016).


BACKGROUND: Interruptions in cardiopulmonary resuscitation (CPR) to obtain vascular access reduces blood flow to vital organs. Tibial intraosseous (TIO) access may be a faster alternative to intravenous (IV) access for delivery of vasoactive medications. The purpose of this study was to examine the differences in pharmacokinetics and pharmacodynamics of TIO- and IV-delivered epinephrine.

MATERIALS AND METHODS: A prospective, between subjects, experimental design comparing Cmax, Tmax, return of spontaneous circulation (ROSC), and time to ROSC. Adult male swine were divided into three equal groups (n = 7) all received CPR and defibrillation: the second group received IV epinephrine and the third group received tibial intraosseous epinephrine. Swine were placed in cardiac arrest for 2 min before CPR was initiated. After 2 min of CPR, epinephrine was delivered by IV or TIO, and serial blood samples were collected over 4 min.

RESULTS: There were no significant differences between IV versus TIO epinephrine in achieving ROSC, time to ROSC, and Cmax. A one-way analysis of variance demonstrated a significant difference between the IV and TIO groups in Tmax (P = 0.025). A Fisher exact test demonstrated a significant difference between IV epinephrine versus CPR/Defib only (P = 0.035) and TIO epinephrine versus CPR/Defib only (P = 0.010) in achieving ROSC. A multivariate analysis of variance showed significant differences in IV versus intraosseous epinephrine concentration at specific time intervals: 60 (P = 0.023), 90 (P = 0.001), and 120 (P < 0.000) sec.

CONCLUSIONS: In the context of ROSC, epinephrine delivered via TIO route is a clinically relevant alternative to IV administration. When IV access cannot be immediately obtained in cardiac arrest patients, TIO access should be considered.


Wong, M.R., Reggio, M.J., Morocho, F.R., Holloway, M.M., Garcia-Blanco, J.C., Jenkins, C. and Johnson, A.D. (2016) Effects of intraosseous epinephrine in a cardiac arrest swine model. The Journal of Surgical Research. 201(2), p.327-33.

doi: 10.1016/j.jss.2015.11.015.

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