Alternative Routes for Drug Adnistration

Endotracheal Route

The following drugs can be administered safely and effectively by the endotracheal route:

• ADRENALINE
• ATROPINE
• SALBUTAMOL

DO NOT ADMINISTER ANY OTHER DRUGS BY THIS ROUTE.

Editor's Note:
The follow two Paragraphs and two Tables were added by me following distribution of RAV Clinical Circular CLI 2007/02:

Drug doses are generally doubled when administered via the ETT route, with the exception of ADRENALINE and ATROPINE for paediatric patients. The following table summarises current drug multiplication factors:

Drug	Adult Factor	Adult CPG's Affected
ADRENALINE	x 2	VF & Pulseless VT Asystole PEA
ATROPINE	x 2	Asystole PEA
SALBUTAMOL	x 2	Asthma

Drug	Paed Factor	Paed CPG's Affected
ADRENALINE	x 10 (0.1 mg/kg)	Asystole/Severe Bradycardia VF & Pulseless VT
ATROPINE	x 1.5 (0.03 mg/kg)	Asystole/Severe Bradycardia
SALBUTAMOL	x 2 (10 mcg/kg initial) (5 mcg/kg subsequent)	Asthma

All drugs delivered by the ETT route should be diluted to the required volume with NORMAL SALINE.

To administer drugs via the endotracheal route:

- Place an approved catheter down to the end of the endotracheal tube.

- Spray the appropriate volume of the desired solution down the catheter.

- Flush the suction catheter using NORMAL SALINE to ensure the proper dose of active drug reaches the airway mucosa.

- Follow the administration of the drug with five forceful ventilations.

Adult

The ETT route is thought to be less effective than the IV route. All ETT drugs should be diluted with NORMAL SALINE to make 10mls.

Paediatric

The drugs should be diluted with NORMAL SALINE as required and the total volume administered via the ETT route should not exceed:

newborn and infant	1 ml
small child	5 ml
large child	10 ml

For ADRENALINE, the endotracheal dose is TEN times the initial IV dose, i.e. 10x 0.01mg/kg in 1:1000 dilution (0.1 mg/kg), diluted as above.

Intraosseous Route

The use of the intraosseous route is justified in all age groups in circumstances where life saving intravenous drugs and/or fluid are required and intravenous access is not possible including:
  - Where ETT is indicated and sedation / paralysis pre or post ETT is required and timely intravenous access is not possible
  - Cardiac Arrest where there will be a delay in gaining IV access

Contra-Indications
  - If any part of the limb is traumatised or infected
  - The proposed site cannot be adequately cleansed
  - Osteogenesis Imperfecta

Distal Attempts into the same limb where an attempt has already been made, should not occur

Precautions
  - Follow the relevant clinical work instruction for OI device (see IO Needle and IO Gun)
  - Care should be taken not to inject air
  - Beware of extravasation

Complications
  - Necrosis of surrounding soft tissue due to extravasation
  - Infection of bony tissue
  - IO insertion is usually not painful in the conscious patient. It may on occasion be painful though to administer drugs/fluids through the IO cannula

Local Anaesthesia
  - If patient conscious, administer IO Lignocaine 1% anaesthesia prior to infusing drugs/fluid once confirmed patent
     - Adult (>30kg): 0.5mg/kg (max 40mg IO)
     - Child (<30kg): 0.5mg/kg (max 20mg IO)

Note: The distal tibial site is preferred in adults and children 4 years and older.