# Pushing meds down the ET tube



## Shishkabob (Aug 26, 2010)

So, I know it has fallen out of fashion, but does anyone still have LEAN for their ET tubes?


I ask for a simple reason:  I suck at IVs as it is, let alone trying to stick someone that has no blood pressure and that I won't get a flash on (Cardiac arrest), and we don't have IOs for adults.  

That pretty much leaves me with just drugs down the ET tube in an "OH CRAP THIS ISN'T GOOD" situation, of course after the other options are exhausted, including EJ.




I'm going to find my MCs email and ask him the question on its use as it's not in our protocols (obvious reasons), and I also don't see me having to worry *much* about a cardiac arrest call anytime soon, but just thought I'd ask.


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## huey28 (Aug 26, 2010)

well whats your main problem with iv's???? thats something you are gonna have to work on..


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## AnthonyTheEmt (Aug 26, 2010)

Actually yes. In Fresno, we can put drugs down the tube. I have to review what meds can go down, but can tell you for sure that it is allowed.


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## MasterIntubator (Aug 26, 2010)

Rarely.  If IVs are a problem, we just I/O them ( Jamshidi/Illinois or the Easy I/O ).

The only time I usually consider it, is EPI in the case of Status asthmaticus code.   Works like a charm and improves compliance


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## Aidey (Aug 27, 2010)

This is one of those situations where practice hasnt caught up to science. Studies have shown that there is zero systemic absorption of meds put down the tube. There are exceptions for local acting meds like albuterol, or epi, which have a direct affect on the lungs.


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## MrBrown (Aug 27, 2010)

No we have IO now but it sounds like you need lots of IV practice, Mr Laerdel might make a good patient I know he has at my station


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## Hellsbells (Aug 29, 2010)

My question is:

Why are you skilled at intubation, but not on IV's? In my experience intubation is the harder skill.


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## 8jimi8 (Aug 29, 2010)

Mayhaps someone needs to get some time training in an ER.  I'm betting your clinical educator can arrange for a few 8 hour shifts starting IVs at a local hospital.

Seriously dude?  Are you just scared?  can't get that AC go for the BICEP...

You think you won't be able to get an EJ?

Don't have adult IO in the protocols.... can't you call online medical control and get a verbal order?!


Linuss, after that last major chat session I was mucho impressed with your ... "resourcefulness..." don't make me start making fun of you!


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## GothamEMS (Aug 29, 2010)

MasterIntubator said:


> Rarely.  If IVs are a problem, we just I/O them ( Jamshidi/Illinois or the Easy I/O ).



From my experience, I 100% agree.


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## legion1202 (Sep 3, 2010)

Correct me if I am wrong but from what I`ve been told is when you ET someone they have a high chance of puking. If they puke and even though you suction there is still :censored::censored::censored::censored: that could be in there lung which in return could cause the drugs not to work. If I were you I would practice doing IV's until you can do it in your sleep. At least I plan on too (i just started P1)


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## MasterIntubator (Sep 3, 2010)

You are right, there may be a chance.  A high chance?  Unlikely.  If the person has coded, your chances of them actively puking are slim to none.  But you will have the typical saliva, mucos, chicken noodle soup pooled down there.
On consious sedation, elective intibation, etc... yes, your chances are much greater... still not high though.
I only base this on a couple hundred intubations a year for the past 20 some years, and yes it does happen... not that much. ( some folks may have more experience with it, and the numbers may vary ).  
As long as you don't forcefully ventilate without properly suctioning, you won't get a great deal in the lungs, and if you do.... a little tracheal suctioning works pretty good.
Pulmonary edema, pyrothorax can mess your world up directly effecting the drug absorption.


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## EMTinNEPA (Sep 4, 2010)

Intubation (while a difficult procedure at times) is easier than IV access imo.  Intubation is all based on landmarks.  IV access is practically blind... you are trying to slip a little tube inside of another little tube!  However, on topic, meds down the ET tube are not preferable for several reasons.  For one, there is no way for you to tell how much of the medication is actually absorbed.  For another, you are typically doubling the dose for the ET route... that means 2mg Epi and 2mg Atropine for Asystole/PEA/EMD... that's 40cc of fluid PER ROUND of medications!  Do me a favor... let me put 40ccs of fluid into your lungs every three to five minutes.

Linuss... have you considered pestering your employer to purchase adult IOs?  If not, you can always go for an EJ.  EJs can be really nice in a cardiac arrest... turn the head to the side, throw in the IV, secure it, turn the head straight, drop the tube... everything ALS is above the neck... now you can just sit at the head and do your thing and let the BLS providers do theirs!  Also, have you considered this?: http://www.veinlite.com/pics/Veinlite EMS Flyer e-mail.jpg

EDIT: Just re-read your post and saw that EJ wasn't an option... my bad.


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## Dominion (Sep 5, 2010)

Our protocols call for drugs down the tube as an ABSOLUTE last resort and only after MC has been contacted for orders.  My service doesn't carry EZ IO, we only carry Jamshidi IO and while I've never done it I've been told they are nigh impossible to get placed on an adult patient.  The ONE time I've done an EJ I didn't see the vein at all but I remembered where the thing ran so I went anatomical.  For concern on flash I was taught to take the end cap off the IV Needle (the cap furthest from the needle) and attach a 3 or 10 cc syringe to it.  Insert IV while aspirating, 

I was surprised at how easy it was, if you know generally "OK the EJ runs from here to here" and line up your needle with that anatomical location you should hit it.  If you don't see it that is.  

What issues are you having with IV's?   My biggest problem has been angle, I enter entirely too steep.


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## himynameismj (Oct 15, 2010)

Linuss said:


> So, I know it has fallen out of fashion, but does anyone still have LEAN for their ET tubes?
> 
> 
> I ask for a simple reason:  I suck at IVs as it is, let alone trying to stick someone that has no blood pressure and that I won't get a flash on (Cardiac arrest), and we don't have IOs for adults.
> ...



And then God said, for you.. I give you SQ / IM


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## Smash (Oct 15, 2010)

himynameismj said:


> And then God said, for you.. I give you SQ / IM



Hmmmm... SQ meds in an intubated patient? Interesting idea...


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## TransportJockey (Oct 15, 2010)

himynameismj said:


> And then God said, for you.. I give you SQ / IM



SQ/IM for ACLS drugs? Are you kidding or just not paying attention at all in class?


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## CAO (Oct 15, 2010)

Right Patient, Right Drug, Right Dose, Right Time, Right...

...Oh, crap.


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## himynameismj (Oct 15, 2010)

he wasn't talking about ACLS. He mentioned Cardiac Arrest, but right there you can give Epi and Atropine 2 to 2.5x the dose down the ETT.


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## TransportJockey (Oct 15, 2010)

himynameismj said:


> he wasn't talking about ACLS. He mentioned Cardiac Arrest, but right there you can give Epi and Atropine 2 to 2.5x the dose down the ETT.



LEAN (or NAVEL) is what kind of drugs for the most part? That's right. ACLS. Lido, Epi, Atro, and Vasopressin, plus Narcan. Generally ACLS in an arrest means code drugs. 
You said SQ/IM up there, nothing about give drugs ET.


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## himynameismj (Oct 15, 2010)

oh damn, i should have read the first post in full. i thought he was just saying in general he was having trouble w/ iv access.


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## TacoMEDIC (Oct 23, 2010)

Since ICEMA approved the use of IOs for adult pts we no longer give any meds down the tube. No need to.


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## Melbourne MICA (Oct 24, 2010)

*ET drugs*

Waste of time and simply a measure of desperation. Can't say I've ever seen an arrested pt who made it back on ET delivered drugs alone though the ET route is still in most guidelines including ours. As others have pointed out get the IV in or use IO otherwise use diesel therapy and hope their is time for the ED docs to get the IV you should have gotten, to do a cutdown or a central line.

MM


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## wiggy762 (Oct 24, 2010)

*Gotta love the tough-love crowd...*



ET drugs were A-OK back in early 90's and I based my ACLS treatment steps around this route. 

It was a bit of a shock (no pun) to find that they had fallen out of favor, requiring a revamp of my steps.

NAVEL was awesome, but it passes the smell test regarding the unknown-ness of hoe much drug had been absorbed. 

So, why no IOs? They are the best on codes...no more worry about multiple lost IVs.


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## TransportJockey (Oct 24, 2010)

wiggy762 said:


> ET drugs were A-OK back in early 90's and I based my ACLS treatment steps around this route.
> 
> It was a bit of a shock (no pun) to find that they had fallen out of favor, requiring a revamp of my steps.
> 
> ...



For your area, IOs are not too common simply cause BCFD and AFD are the only ones who really carry good IO devices last I checked. I think AAS only has Jemshidi needles for pedis, BCFD has the BIG, and AFD has the EZ. 
BTW, good to see another NM person


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## socalmedic (Oct 24, 2010)

ventura has a protocol for epi/atropine to be injected in the toung (IL) up to 3ml in cardiac arrest.


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## wiggy762 (Oct 25, 2010)

*Good to see you too! Go NM!*

I hope that will be changing since EMSA is training on the EZ IO as well as the Jamshidi.

I hope more services move towards to the EZ IO.





jtpaintball70 said:


> For your area, IOs are not too common simply cause BCFD and AFD are the only ones who really carry good IO devices last I checked. I think AAS only has Jemshidi needles for pedis, BCFD has the BIG, and AFD has the EZ.
> BTW, good to see another NM person


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## TransportJockey (Oct 25, 2010)

wiggy762 said:


> I hope that will be changing since EMSA is training on the EZ IO as well as the Jamshidi.
> 
> I hope more services move towards to the EZ IO.



CNM (When I was there in 09) was still just doing Jamshidi training. I think it's a money issue for AAS to equip all their buses with EZs though. 
Although my new service here in TX uses EZs, and I have full permission to use them whenever I feel the need (eg codes, CTD pts that are hard sticks), and in whichever location  Idesire.


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## swissmedic (Oct 26, 2010)

First we try iv access (90 sec for any crtitical patients) and then EZ-I (I will never miss this great tool). Our protocols call for drugs down the tube as an absolute last resort. If you don`t have io tools, you can try the "VEINLITE"...

http://www.veinlite.com/

I didn`t like it it, you need too much time for this tool...
matt


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