# Giving medication down ET tube



## rhan101277 (Jul 17, 2009)

Maybe this is a dumb question but when placing the ET tube you put it down in between the cords.  Is there another tube that goes down the esophagus for medication purposes at the same time?

Isn't it true that medications given this route have the slowest absorption rate.

In what cases would you use this route if you could find good veins.


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## Shishkabob (Jul 17, 2009)

Are you talking about putting PO drugs down the esophagus in an intubated pt?  PO drugs are the slowest (not counting transdermal).  They have to go through the stomach, into the intestines, then pass through the liver.



Drugs down the ETT, into the lung, are actually fairly quick.  You can give O-LEAN down the tube, but a few places around here are actually pulling back from pushing down the tube.



Granted I'm new to this, but I can't think of a single PO drug you'd give to an intubated pt (in the field).  They are intubated for a reason, and as such you want the quickest route of drug administration, which is IV/IO.


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## JPINFV (Jul 17, 2009)

rhan101277 said:


> Maybe this is a dumb question but when placing the ET tube you put it down in between the cords.


Yes





> Is there another tube that goes down the esophagus for medication purposes at the same time?


 No. 





> In what cases would you use this route if you could find good veins.


None.


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## Shishkabob (Jul 17, 2009)

I lied, there is a drug.


You can use a Nasogastric tube to put activated charcoal down in to the stomach.


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## atropine (Jul 17, 2009)

even in southern Cali were not putting drugs down the et tube anymore.


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## VentMedic (Jul 17, 2009)

There are many meds that we do put through an ETT but they are usually for special respiratory purposes or procedures if given as a liquid. There are also many other meds nebulized for a variety of different effects including reducing pulmonary hypertension, pain control or other off label use of meds such as lasix in the neonatal population.

However, for prehospital, peripheral IVs, including the EJ, and the IO are preferable. 



rhan101277 said:


> Is there another tube that goes down the esophagus for medication purposes at the same time?


 
Here is an article that will explain many things about the OG, NG, NJ, G-Tube and J-Tube. 

http://www.radiographicceu.com/article24.html

Meds, fluids and feedings will be given down these tubes and you should have already seen most of them if you have assessed your patients properly from home care situations and LTC facilities. 

We usually drop an NG or OG tube when using a BVM to decompress the stomach. If intubated with thoughts of requiring a ventilator, the OG is placed rather than an NG for the long haul to reduce the possiblity of an infection leading to PNA.


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## ResTech (Jul 17, 2009)

In an emergency situation pre-hospital, only a select few drugs are able to be administered down the tube... Lidocaine, Epi, Atropine, and Narcan (LEAN). Many EMS systems are getting away from giving drugs down the tube due to unreliable absorption rates and questionable efficacy. It was once thought that due to the vast vascular network in the lungs that ETT admin was close to IV but they are finding this not to be true. 

Maryland is one State that took ETT admin of meds out of the protocol. Its either IV or IO.


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## rhan101277 (Jul 18, 2009)

ResTech said:


> In an emergency situation pre-hospital, only a select few drugs are able to be administered down the tube... Lidocaine, Epi, Atropine, and Narcan (LEAN). Many EMS systems are getting away from giving drugs down the tube due to unreliable absorption rates and questionable efficacy. It was once thought that due to the vast vascular network in the lungs that ETT admin was close to IV but they are finding this not to be true.
> 
> Maryland is one State that took ETT admin of meds out of the protocol. Its either IV or IO.



How does this fluid effect oxygen absorption?  I know gases diffuse, but fluid medicines in the lungs how does that work?


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## Shishkabob (Jul 18, 2009)

My money is on "very little to none"


When putting drugs down the ETT, you have to double the dosage just to get the same effect as doing it IV.

Even considering double the dosage, that's only a few mls of space in a 5-6l area.


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## ResTech (Jul 18, 2009)

All in all, the small volume of fluid from the medications isn't gonna cause any problem with diffusion distance or actual oxygenation. However, in cases of say CHF or Adult Respiratory Distress Syndrome (ARDS) where fluid in the lungs is already a problem, it doesn't make sense to be putting more fluid in the lungs even though in small amounts.


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## Shishkabob (Jul 18, 2009)

ResTech said:


> However, in cases of say CHF or Adult Respiratory Distress Syndrome (ARDS) where fluid in the lungs is already a problem, it doesn't make sense to be putting more fluid in the lungs even though in small amounts.



Let alone Epi ... ^_^


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## falcon-18 (Jul 18, 2009)

the medication in ETT is (NAVEL) all of it in double dose.

I think any medication in PO you can give by NGT. 

I am not sure :unsure: . but I am see some doctors give by NGT.


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## ResTech (Jul 18, 2009)

No you wouldnt give Epi to a CHF or even ARDS patient normally, but if they happen to arrest than you would... admittingly if someone arrests due to CHF they are long gone anyway... just a principle to be cognizant of.


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## VentMedic (Jul 18, 2009)

falcon-18 said:


> the medication in ETT is (NAVEL) all of it in double dose.
> 
> I think any medication in PO you can give by NGT.
> 
> I am not sure :unsure: . but I am see some doctors give by NGT.


 
For the code situation the "V" in NAVEL is now Vasopressin. 

Most meds taken by PO can be given by NGT provided they can be made into a form the tube can accomondate and provided they are not a time (extended) release med or capsule where changing the form changes the release time.


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## emtjack02 (Jul 18, 2009)

falcon-18 said:


> the medication in ETT is (NAVEL) all of it in double dose.
> 
> I think any medication in PO you can give by NGT.
> 
> I am not sure :unsure: . but I am see some doctors give by NGT.



If giving ntg po that would be extended release, not something I assocciate with prehospital needs. imho


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## ResTech (Jul 18, 2009)

Pre-hospital no PO meds are gonna be given by NG tube... especially considering the only time a NG tube is placed is during arrests. 

However, PA protocols do allow for PO benedryl pre-hospital for mild allergic reactions.


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## VentMedic (Jul 18, 2009)

ResTech said:


> Pre-hospital no PO meds are gonna be given by NG tube... especially considering the only time a NG tube is placed is during arrests.


 
Not exactly. Since many of your patients from LTC facilites or home care will have g-tubes of some kind and maybe even NGT depending on time of placement and reasons. It is always wise to check what meds (especially PRN) have been recently given by the RNs or family members down the NGT or peg(G-Tube) so you can inform the ED staff so there won't be a double dose given or if your patient goes somnolent or apneic after you also give something for sedation.

NG tubes are also not just placed during cardiac arrests. We may place one during transport for N/V or if intubation is anticipated. If you do CCT or Flight, there is a fairly long list of reasons to have an NGT placed.

Like many of the venous access devices, the NGT is the most under utilized device that is within the scope of practice for most Paramedics.


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## ResTech (Jul 18, 2009)

Im talking straight 911, station to scene EMS... it is safe to say PO meds are not ever gonna be administered pre-hospital especially by an NG tube. The absorption rate is way to slow. For one, you kinda have to carry PO meds in your drug box for PO administration to even be considered. No Paramedic service I have ever seen carries PO meds except for ASA which when chewed gets absorped pretty quick. 

And in over a decade of career experience working for FD's and running with my volly EMS service, I have never seen a PO med given pre-hospital (except for ASA of course).  

No protocol I have seen allows for an NG tube insertion for N&V and doubtful med command is gonna give orders for one given a short transport time.


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## rhan101277 (Jul 18, 2009)

I guess I need to re-phrase my question. I want to make sure I understand how the medicine makes it to the bloodstream. Are individual molecules able to pass through the alveoli to the capillaries?


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## VentMedic (Jul 18, 2009)

ResTech said:


> Im talking straight 911, station to scene EMS... it is safe to say PO meds are not ever gonna be administered pre-hospital especially by an NG tube. The absorption rate is way to slow. For one, you kinda have to carry PO meds in your drug box for PO administration to even be considered. No Paramedic service I have ever seen carries PO meds except for ASA which when chewed gets absorped pretty quick.
> 
> And in over a decade of career experience working for FD's and running with my volly EMS service, I have never seen a PO med given pre-hospital (except for ASA of course).


 
What I am trying to tell you is the meds don't have to be given by you. The nurses or family members could already have given the meds prior to your arrival. I consider ALL meds given from the time the emergency starts till the patient's arrival to the ED as prehospital. Thus, some EMS providers believe, *wrongly*, that since there is not an IV established, no meds were given or don't think that there may have be a PO med given through that tube which will take effect shortly have they give something IV. We do have to reverse patients in the ED because the Paramedics did not take into consideration the other meds.  It may not mean you withhold what you are giving but you need to be prepared for whatever happens when all the meds are in the body.

All paramedic units should have the capabilty of sinking an NGT for the unconscious patient especially with vomiting.


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## VentMedic (Jul 18, 2009)

rhan101277 said:


> I guess I need to re-phrase my question. I want to make sure I understand how the medicine makes it to the bloodstream. Are individual molecules able to pass through the alveoli to the capillaries?


 
JEMS article:
http://www.jems.com/news_and_articles/columns/Rodenberg/NAVEL_Contemplation_Part_I.html


http://books.google.com/books?id=bt...Pr9oFn&sa=X&oi=book_result&ct=result&resnum=6


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## falcon-18 (Jul 18, 2009)

so most medication given PO can be given through NGT. yeah I know it is not 

in emergency . It is take long time for absorption NOT for paramedic, only in 

gastric lavage,vomiting, during arrest and long transport in flight. 

now I am sure .  

thanks


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## Shishkabob (Jul 18, 2009)

And activated charcoal...


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## ResTech (Jul 18, 2009)

Based on the context of the discussion, I think were talking about what we as pre-hospital providers give directly, not what was given prior to EMS which will be ascertained during the assessment.


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## Shishkabob (Jul 18, 2009)

EMS can give activated charcoal.


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## ResTech (Jul 18, 2009)

Yes, and activated charcoal....

Vent, good Jems article... your like the search queen of finding good articles!


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## falcon-18 (Jul 18, 2009)

Linuss said:


> EMS can give activated charcoal.



yes. you can give charcoal .


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## Shishkabob (Jul 18, 2009)

That was a statement, not a question.


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## VentMedic (Jul 18, 2009)

ResTech said:


> Vent, good Jems article... your like the search queen of finding good articles!


 
Yes it is amazing what a good search engine with a university system and med school can do.


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## Shishkabob (Jul 18, 2009)

VentMedic said:


> Yes it is amazing what a good search engine with a university system or med school can do.



My college pays for those types of search engines.  I just can't remember the addresses / passwords for the life of me.


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## ResTech (Jul 18, 2009)

I never think to use my Colleges search engine.... Im so used to using Google.


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## VentMedic (Jul 18, 2009)

ResTech said:


> I never think to use my Colleges search engine.... Im so used to using Google.


 
Google Scholar is fairly decent.


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## JPINFV (Jul 19, 2009)

Between Google Scholar and Pubmed you can find most articles. I especially like that Pubmed automatically sorts out the review articles.


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## rhan101277 (Jul 19, 2009)

VentMedic said:


> JEMS article:
> http://www.jems.com/news_and_articles/columns/Rodenberg/NAVEL_Contemplation_Part_I.html
> 
> 
> http://books.google.com/books?id=bt...Pr9oFn&sa=X&oi=book_result&ct=result&resnum=6



Thanks for the link, that article was a good read.  Seems many things are still uncertain about medicine effectiveness, when give this way.  With some medicines it takes 10x the normal dose to be just as effective as a IV dose would be.  Seems like a last route of medicine administration after trying IV and IO.  There are only 4 medicines that can be given this route correct?

Lasix
Epi
Atropine 
Nitroglycerin


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## Shishkabob (Jul 19, 2009)

Nope.

L is Lidocaine and N is Narcan.


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## ResTech (Jul 19, 2009)

And you can also Diazapam (Valium)


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## Shishkabob (Jul 19, 2009)

ResTech said:


> And you can also Diazapam (Valium)



Many places in North Texas have done away with Valium, going for the MAD device.


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## ResTech (Jul 19, 2009)

Maryland also took Diazapam out of the protocols except for use during WMD since it is largely in the stockpiles. 

Ativan replaced diazapam which is nice for seizures since it can be given IM. No more PR administration.


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## Shishkabob (Jul 19, 2009)

Opps, I meant done away with ETT Valium.  Gah too late to edit.


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## falcon-18 (Jul 19, 2009)

ResTech said:


> And you can also Diazapam (Valium)



can you give valium through ETT ?  :unsure:


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## medic417 (Jul 19, 2009)

ResTech said:


> Ativan replaced diazapam which is nice for seizures since it can be given IM. No more PR administration.



Valium can be given IM as well.

In my experience Ativan has failed to break seizures as well as Valium does.  This is another case of it would be better if the service has more than one option.


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## usafmedic45 (Jul 19, 2009)

> Valium can be given IM as well.



It CAN be, but it is not a recommended route especially in patients with low body mass or poor circulation and an IMMEDIATE need for the onset of medication action.  The actual prescribing information for Valium (found here: http://www.rocheusa.com/products/valium/pi_iv.pdf) actually uses the phrase "_by far preferred_" to describe the preference for the IV route to the IM route.  This is in part due to the slower absorption of diazepam from muscle versus the onset of effects from IV administration, the risks of injection site complications (due to what the medication is dissolved in), anecdotal reports of slightly increased rates of paradoxical reactions with use of IM administration vs IV, and poorer correlation between dose and effect in IM administration vs IV (in other words, difficulty in titrating the dose needed to control the seizures which could lead to excessive dosing of the patient or prolonging of the seizure activity through persistent underdosing).  I would administer it rectally before I thought about giving it IM.


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## usafmedic45 (Jul 19, 2009)

> In my experience Ativan has failed to break seizures as well as Valium does.



Please refer to the cartoon at the bottom left:






Then go read the 2002 article by Cock and Shapira in QJM on the subject (here: http://qjmed.oxfordjournals.org/cgi/reprint/95/4/225 ). I think you'll find something a little more substantial than too many EMS worker's favorite defense for their preferences of medications or procedures ("in my experience").  

As the saying goes "Relying on your experience alone simply means you're going to keep making the same mistakes with an ever increasing level of confidence." 




> This is another case of it would be better if the service has more than one option.



Then it would be wise to carry something other than another benzodiazepine.  However, most medical directors are going to be loathe to give their medics barbiturates, etc for good reason.


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## Ridryder911 (Jul 19, 2009)

medic417 said:


> Valium can be given IM as well.
> 
> In my experience Ativan has failed to break seizures as well as Valium does.  This is another case of it would be better if the service has more than one option.



Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level. 

R/r 911


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## medic417 (Jul 19, 2009)

usafmedic45 said:


> Then it would be wise to carry something other than another benzodiazepine.  However, most medical directors are going to be loathe to give their medics barbiturates, etc for good reason.



As with all meds not one size fits all.  This is one reason procedures like RSI are being pulled from many services.  Patient doesn't respond properly but no other med or dosage choices.  Sometimes drugs of same family work better than others.


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## medic417 (Jul 19, 2009)

Ridryder911 said:


> Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.
> 
> R/r 911



My bad I went with the presumption that was understood.  Thanks for the term correction so the newer Paramedic students will not be confused.


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## usafmedic45 (Jul 19, 2009)

> Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.



Which is why (along with the often marked serum level swings) it can not be used for long term control.



> As with all meds not one size fits all.



You will not find a more staunch supporter of that bit of truth than myself. 



> Sometimes drugs of same family work better than others.



This is true but see my points below on the hazards of having backups. 



> This is one reason procedures like RSI are being pulled from many services.



Actually that's a gross oversimplification, but let's not sidetrack this thread by dissecting that issue just this second. 



> Patient doesn't respond properly but no other med or dosage choices.



How often does that actually happen in the field?  When I did quality control from 1999 to 2001, seizure calls made up ~1% of our cases and intractable seizures made up less then 10% of those cases (in other words, about 0.0001%).

I am not arguing that having choices is a bad thing, I am arguing that the current crop of ALS providers are not a group I would be throwing phenytoin or pentobarbital and tell them "Here you go in case you need it".  Simply put there is too little knowledge base among EMS personnel as a group (as often demonstrated in this and, to even greater degrees, other EMS forums) to warrant opening the floodgates to every backup medication we could need for a life-threatening emergency.  Technically one could argue that seizures are- in an established epileptic without other complicating factors with high mortality of their own (intracranial bleed, infectious disease, drug overdose, etc)- not a frank life-threatening condition because of the low mortality associated with them.  

Sudden unexpected death in epilepsy is an issue in a small subset of the population (1 out of 1,000 roughly, accounting for about 10% of deaths in patients with a diagnosis of one form or another of epilepsy) and death from absolutely intractable status epilepticus is similarly uncommon.  This is not a reason why active seizing- especially that which does not respond to an initial dose of benzodiazepines- should not be considered to be an indication for transport without delay to the closest emergency department.  The field is simply no place to play around by mixing multiple benzos in addition to whatever the patient may be taking for long term control of the underlying issues.


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## medic417 (Jul 19, 2009)

usafmedic45 said:


> I am not arguing that having choices is a bad thing, I am arguing that the current crop of ALS providers are not a group I would be throwing phenytoin or pentobarbital and tell them "Here you go in case you need it".  Simply put there is too little knowledge base among EMS personnel as a group (as often demonstrated in this and, to even greater degrees, other EMS forums) to warrant opening the floodgates to every backup medication we could need for a life-threatening emergency.  Technically one could argue that seizures are- in an established epileptic without other complicating factors with high mortality of their own (intracranial bleed, infectious disease, drug overdose, etc)- not a frank life-threatening condition because of the low mortality associated with them.
> 
> Sudden unexpected death in epilepsy is an issue in a small subset of the population (1 out of 1,000 roughly, accounting for about 10% of deaths in patients with a diagnosis of one form or another of epilepsy) and death from absolutely intractable status epilepticus is similarly uncommon.  This is not a reason why active seizing- especially that which does not respond to an initial dose of benzodiazepines- should not be considered to be an indication for transport without delay to the closest emergency department.  The field is simply no place to play around by mixing multiple benzos in addition to whatever the patient may be taking for long term control of the underlying issues.



I see your point and agree to a point.  My opinion is that if a medical director can not trust the Pre Hospital Medical Professional to be educated enough to do the job properly they should refuse to allow that person to operate under their license.

I also think based on very Rural EMS where we have long patient contact times.  One service is over an 90 miles of bad roads to the nearest hospital.  So you need options if first choice fails.


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## usafmedic45 (Jul 19, 2009)

> One service is over an 90 miles of bad roads to the nearest hospital.



Two questions:  Where the hell do you work?  Also are you talking "90 miles to the nearest good hospital" or "90 miles to anything that can legally call itself a hospital"?



> I see your point and agree to a point. My opinion is that if a medical director can not trust the Pre Hospital Medical Professional to be educated enough to do the job properly they should refuse to allow that person to operate under their license.



Likewise, but unfortunately many (most?) medical directors are about as involved in their services' medics as a mother in a Detroit project is with her children (in other words, only gets off their butt to issue beatings, whether deserved or not). 



> So you need options if first choice fails.



Agreed.

Then if you are that far out and have a progressive medical director who is actively involved, you might look into trying to get the protocol expanded. However, if it were me, I would prefer a benzo (lorazepam being my choice) and a barbiturate (pentobarbital in my case) for use in case of intractable seizures that do not respond to the benzo.  To me, that makes more sense than switching from one to the other among the same class.  However, I do not see as being any more practical than the option of also adding propofol as third line agent for seizures that do not yield to the first tow medications which was something I once discussed over dinner as an academic exercise with my medical director and one of his deputies.


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## medic417 (Jul 19, 2009)

usafmedic45 said:


> Two questions:  Where the hell do you work?  Also are you talking "90 miles to the nearest good hospital" or "90 miles to anything that can legally call itself a hospital"?
> 
> Then if you are that far out and have a progressive medical director who is actively involved, you might look into trying to get the protocol expanded. QUOTE]
> 
> ...


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## usafmedic45 (Jul 19, 2009)

medic417 said:


> usafmedic45 said:
> 
> 
> > Two questions:  Where the hell do you work?  Also are you talking "90 miles to the nearest good hospital" or "90 miles to anything that can legally call itself a hospital"?
> ...


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## medic417 (Jul 19, 2009)

usafmedic45 said:


> medic417 said:
> 
> 
> > I wish you the best of luck with your new medical director and if I can be of any service in pulling together the scientific literature, etc to support any needed changes to protocols or to protect the current ones, feel free to PM me.
> ...


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## MrBrown (Jul 19, 2009)

We still have the option of adrenaline going down the ET tube in an arrest but this is being discouraged as the evidence is not supporting it and we are moving towards IO access.


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## Smash (Jul 20, 2009)

Ridryder911 said:


> Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.
> 
> R/r 911



Actually it does 'break' seizures.  All benzodiazepines bind to ligands on GABA receptors that are known a BZD receptors (benzodiazepine receptors)

Through magical neurochemcial secret business this increases the effects of GABA in the brain.  GABA is of course the major inhibitory neurotransmitter, so propagation of abberant signals in the brain (the seizure) is reduced and/or terminated, thus terminating the seizure (extemely truncated sleep deprived version for general consumption

Generalized seizure activity increase neuronal activity by over 250%, burning up fuel and oxygen and creating waste that is unable to be cleared quickly enough and eventually destroying brain cells.

If we gave something to just relax the muscles and allow unchecked neurological activity to continue we would be allowing the brain to continue frying.  Pancuronium or vecuronium relax the muscles but allow seizure activity (as distinct from convulsive activity) to continue unabated, and of course there is no way that we would give either to a patient in status epilepticus because we can't monitor the seizure activity.


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## paramedic007 (Jul 21, 2009)

*Its kinda complicated*

I work as an educator with UCLA School of Medicine, and when I teach ACLS classes we have been (for the passed 4 years) de-emphasizing giving medications via the ETT here are the reasons why AHA recommended this:
Efficacy of the medication given via the ETT,
It has unpredictable as far the  benefits to the patient when you give the drug this way,
there is no data that shows how effective or how quickly the medication would reach its target organ if it will at all.    

Thus in the 2005 guidelines IV or IO are the most desireable routes because we know that giving medications IV or IO are predictable and rapid, you give a medication IO it is just as effective as IV and it becomes available in the bloodstream immediately upon insertion.  

Remember back to paramedic training...aspiration is a bad thing...why would we want to aspirate someone on purpose??


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## usafmedic45 (Jul 21, 2009)

> Remember back to paramedic training...aspiration is a bad thing...why would we want to aspirate someone on purpose??



You do understand WHY aspiration (in the sense of gastric contents) is bad and the difference between what epinephrine for example and a partially digested pepperoni pizza and a couple of glasses of beer right will do to the lungs?  I've never seen nor heard any documented cases of aspiration pneumonitis from administration of any of the medications previously recommended for endotracheal administration.  I do see what you are trying to get at, but please let's not confuse the less astute amongst us anymore than they already are.


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## VentMedic (Jul 21, 2009)

usafmedic45 said:


> I've never seen nor heard any documented cases of aspiration pneumonitis from administration of any of the medications previously recommended for endotracheal administration.


 
The jury is still out on that.  We do have some studies on saline down the ETT which is why we now use sparingly if at all when suctioning. NICU has pretty much outlawed it in some hospitals.   I do remember the day when we practically drowned the patient and then suctioned it out.  Those days are gone except during bronchoscopies.


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## Shishkabob (Jul 21, 2009)

VentMedic said:


> NICU has pretty much outlawed it in some hospitals.



I'd like to think that 2ml in a 6l space is much different from 1ml in a 1l space, and as such would lead to more complications in the NICU as opposed to a normal ICU.


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## VentMedic (Jul 21, 2009)

Linuss said:


> I'd like to think that 2ml in a 6l space is much different from 1ml in a 1l space, and as such would lead to more complications in the NICU as opposed to a normal ICU.


 
My remarks are also in reference to the adult ICU literature.  We used to do an average of 2 to 5 ml per suction on an adult.


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## Shishkabob (Jul 21, 2009)

Oh it wasn't meant in a combative nature at all.  I struggled with how to phrase it >_<


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## JPINFV (Jul 21, 2009)

paramedic007 said:


> Remember back to paramedic training...aspiration is a bad thing...why would we want to aspirate someone on purpose??



Yea.. and last time I checked there's a difference between injecting a load of stomach acid and partially digested food into a vein and injecting narcan or epi, or the other ET tube drugs (except oxygen).


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## zzyzx (Jul 25, 2009)

Paramedic007 wrote, "I work as an educator with UCLA School of Medicine..."

I think you should clarify that you don't work for the school of medicine. You're an ACLS instructor. Sorry to be be anal, but you can't just say that.


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## Shishkabob (Jul 29, 2009)

I lied, there's another drug that can go down the tube--- Albuterol.


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## VentMedic (Jul 29, 2009)

Linuss said:


> I lied, there's another drug that can go down the tube--- Albuterol.


 
Albuterol is most effective if it is in the appropriate particle size and not poured.

However, there are other meds which have specific purposes that can be poured but unless you do Specialty transport such as neo/pedi or Flight, you may not have a need for them as a Paramedic.


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## daedalus (Jul 29, 2009)

JPINFV said:


> Yea.. and last time I checked there's a difference between injecting a load of stomach acid and partially digested food into a vein and injecting narcan or epi, or the other ET tube drugs (except oxygen).



The fluids can still create a diffusion problem. Where I go to school, it is considered bad form to pour fluid down into the lungs. We can actually inject ACLS meds sublingually before resorting to that. The protocol for SL injection is posted on Ventura EMSA's website. 

I hate the idea of anything but gas down the tube. We hear stories of LA county paramedics literally pouring meds down until every time compressions are started on the chest, fluids shoot up through the tube. Why drown your patient in addition to their other problems?


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## JPINFV (Jul 29, 2009)

The question then is, how much (especially if we're ignoring the efficacy question) does it take to cause a diffusion problem worth worrying about and are we talking one dose, or the stupidity of blindly popping caps and pouring down vials until you top off the ET tube like the gas tank of a car driving cross country?

Now, of course, if there are other options like sublingal, then that's awesome and I'm all for it. I just have trouble accecpting arguments like "ZOMG, asperating stomach contents is bad, therefore medications via ET tube is bad" or "X group is a bunch of idiots and manages to completely frack this up, therefore no one should do this."


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## Shishkabob (Jul 29, 2009)

VentMedic said:


> Albuterol is most effective if it is in the appropriate particle size and not poured.



There's a medical director here in DFW named Dr Yamato who oversees most of the mid cities. He's really aggressive in his protocols and gives his medics a lot of leeway.

In status asthmaticus refractory to nebulized albuterol amd all other treatments, he has his medics do albuterol down the tube. Once poured in, the medics turn the pt side to side like a rotisserie (sp) chicken to get the albuterol onto places it was able to nebulized.   He's apparently had great success doing it.


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## VentMedic (Jul 29, 2009)

Linuss said:


> In status asthmaticus refractory to nebulized albuterol amd all other treatments, he has his medics do albuterol down the tube. Once poured in, the medics turn the pt side to side like a rotisserie (sp) chicken to get the albuterol onto places it was able to nebulized. He's apparently had great success doing it.


 

If that medical director was to consult with some Pulmonologists they might be able to explain to him why it is the turning and not the pouring of albuterol down the tube that has the effect.  Believe me, this has been seriously researched even by my RT department through out the years.  Unless that doctor is doing pulmonary function measurements, he has little data to back it up.  The albuterol may also be little more than a lavage to clear some mucus which NS is cheaper and just as effective.


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## emtjack02 (Jul 29, 2009)

Thank you smash.  

Vent I was under the impression that lavaging with saline was not effective that is why they say not to do it..you know other than causing pneumonia (which yeah as far as this current discussion the status trumps the pneumonia).


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## VentMedic (Jul 29, 2009)

emtjack02 said:


> Thank you smash.
> 
> Vent I was under the impression that lavaging with saline was not effective that is why they say not to do it..you know other than causing pneumonia (which yeah as far as this current discussion the status trumps the pneumonia).


 
I mentioned that earlier. We rarely if ever lavage with saline in Neo or Pedi and it is becoming rare in Adults.

JPINFV


> The question then is, how much (especially if we're ignoring the efficacy question) does it take to cause a diffusion problem worth worrying about and are we talking one dose, or the stupidity of blindly popping caps and pouring down vials until you top off the ET tube like the gas tank of a car driving cross country?


 
There are many factors that will affect the absorption rate as well as the pH and solution base of the liquid. If you've ever seen surfactant given down the tube of a neonate you would think we were literally drowning the baby. In fact, we probably would if it was saline given in that same amount. If you look back through the literature for surfantant, you will see the many issues we did have in the early days especially with the different types as well as the synthetic products. 

If you also look at the early studies for ACLS, you will may find the data on why some meds were chosen and some weren't. Sodium Bicarb was also studied at one time but that was discovered to have few to no absorption properties within the lungs but could dissolve mucus temporarily if used in the right ratio as to not cause irritation. I keep a small syringe handy when flying with babies to unclog an ETT instead of reintubating a baby in an isolette in a helicopter.


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## medic417 (Jul 29, 2009)

zzyzx said:


> Paramedic007 wrote, "I work as an educator with UCLA School of Medicine..."
> 
> I think you should clarify that you don't work for the school of medicine. You're an ACLS instructor. Sorry to be be anal, but you can't just say that.



Big difference there.  Do you know for a fact that the above is a fact?


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## Smash (Jul 29, 2009)

emtjack02 said:


> Thank you smash.



You're welcome. I hate to see gross misconceptions thrown around and treated as gospel. 

Very informative posts VentMedic, thank you.


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