ETT Epinephrine
Question# 829
What is BH's recommendation for administration of the 2mg dose of epinephrine via ETT in cardiac arrest, as the directive states as per RBHP for the solution?
Answer:
When looking at the Medical Cardiac Arrest Medical Directive it does mention “as per RBHP” in the “Solution” section, aka the concentration. From there the directive continues to state that patients greater than or equal to 12 years of age should receive a 2mg dose ETT. We recommend diluting in 5 - 10mL NS to create volume needed to reach the pulmonary tree. When calculating that out using 1:1000 Epinephrine, 1mg/1ml solution, that would mean 2ml with an additional 5 - 10ml of normal saline diluent, therefore 7 - 12ml would be going down the ETT. However, when calculating that using 1:10 000 Epinephrine, 0.1mg/1ml solution, that would mean 20ml of fluid, would be needed to reach the 2mg dose. This would be a lot of fluid to put into the lungs.
Multiple studies have demonstrated that lidocaine, epinephrine, atropine, valium, and naloxone are absorbed via the trachea; however, the serum drug concentrations achieved using this route are unpredictable. Intravenous (IV) or intraosseous (IO) are always the preferred routes for drug administration. When unable to obtain such access expeditiously, one may use the endotracheal tube while attempting to establish vascular or IO access. Don’t forget, you can also use the External Jugular (EJ) as an IV access point as well.
IV is considered the best route possible for medication administration with the other routes, listed in order of preference, IO/CVAD/ETT. The use of an IV line allows for controlled delivery of a specific dose of medication directly into the circulatory system. The other routes face some challenges such as rate of push and absorption in an IO, sterility of utilizing someone’s CVAD, and rate of absorption and filling the lungs with fluid using the ETT.
Doses for tracheal administration are 2 to 2.5 times the standard IV doses, and medications should be diluted in 5 to 10 mL of sterile water or normal saline before injection down the tracheal tube.
Therefore, if you are unable to obtain IV/IO/CVAD access to a patient in cardiac arrest, 2mg of 1:1000 Epinephrine diluted in 5 to 10ml of normal saline may be pushed down the ETT tube.
Multiple studies have demonstrated that lidocaine, epinephrine, atropine, valium, and naloxone are absorbed via the trachea; however, the serum drug concentrations achieved using this route are unpredictable. Intravenous (IV) or intraosseous (IO) are always the preferred routes for drug administration. When unable to obtain such access expeditiously, one may use the endotracheal tube while attempting to establish vascular or IO access. Don’t forget, you can also use the External Jugular (EJ) as an IV access point as well.
IV is considered the best route possible for medication administration with the other routes, listed in order of preference, IO/CVAD/ETT. The use of an IV line allows for controlled delivery of a specific dose of medication directly into the circulatory system. The other routes face some challenges such as rate of push and absorption in an IO, sterility of utilizing someone’s CVAD, and rate of absorption and filling the lungs with fluid using the ETT.
Doses for tracheal administration are 2 to 2.5 times the standard IV doses, and medications should be diluted in 5 to 10 mL of sterile water or normal saline before injection down the tracheal tube.
Therefore, if you are unable to obtain IV/IO/CVAD access to a patient in cardiac arrest, 2mg of 1:1000 Epinephrine diluted in 5 to 10ml of normal saline may be pushed down the ETT tube.
References
Advanced cardiac life support (ACLS) in adults - UpToDate