# Drugs through ET tube



## daedalus (Dec 13, 2007)

My heart sinks a bit when I see epi go down the tube. I remember once before I was involved in EMS, I was watching Paramedics on Discovery Health or TLC I cant remember, and they had an arrest. The paramedic applied a thumper like device after she intubated, than decided to push epi down the tube instead of IV. Wondering if outcomes are different when we compare ET epinephrine with IV epi in VFIB. Your thoughts on the effectivness or if you have doe it before?


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## firetender (Dec 13, 2007)

I've done that a few times in my career, and though I don't recall the end results, I know that it was only after exhausting all other options. In those cases, you gotta try everything.

Here's an interesting thought. In cases where an ET tube is used as a delivery vehicle it would stand to reason that for at least a few cycles, anyway, it would be important to ventilate, even if the patient is getting CPR under today's standards, which are de-emphasizing ventillation.


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## Rattletrap (Dec 13, 2007)

I think the AHA is down playing pushing drugs down the tube. 

I can say, from having been there done that, make sure nobody is doing compressions when you push drugs down the tube. Epi and atropine in the eyes hurts.


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## medic001918 (Dec 13, 2007)

Sending drugs down the tube has fallen heavily out of favor.  It continues to fall farther out of favor with the introduction of IO devices that speed time to access.

I have given drugs down the tube in my career, but not in the past couple of years.

Shane
NREMT-P


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## Flight-LP (Dec 13, 2007)

Shane is right, its no longer a favored method. There really is no reason to utilize ET medication administration. For one, most current first line drugs cannot be administered down the tube. Second, with the recent push for better circulation instead of immediate oxygenation, an IV should be placed and drugs administered before the patient is intubated. 

My personal pet peeve with ET med administration is the idiots who actually listened to the old AHA recommendations of 2 - 2.5 x the normal dose down the tube. For those not visualizing the math, it means you just pushed 20 -25 ML of fluid directly into the lungs. Makes me cringe every time I see it!

Get an IV peripherally, centrally, or start an IO. If your going to make the effort to attempt resuscitation, might as well do it right and not half arsed.....


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## Epi-do (Dec 13, 2007)

I've been on runs where drugs were pushed down the tube, but I personally haven't done it since I am currently in medic class.  Once we got EZ-IOs on the trucks, drugs down the tube went by the wayside and no one around here does it anymore.


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## paramediclori (Dec 22, 2007)

We used to be able to, but it has been proven it is ineffective.  Now most guidlines state, if you can not get an IV, go for an IO and push meds that way.h34r:Besides, you always have that chance of it comming right back up the tube.


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## kiwimedic (Dec 23, 2007)

Us Kiwi's either use IV or 3x dose with 10ml NaCI down the ETT but, from Jan 08 it is changing to be either IV or IO via the EZ-IO.


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## Markhk (Dec 24, 2007)

I have to admit I was pretty surprised when I read that VASOPRESSIN could be put down the tube as well.


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## spidermedic (Dec 28, 2007)

Down the tube has definitely gone down the tubes.  My service hasn't been doing it for well over 2 years, which is when the studies were showing it was pretty much a waste of time.

I'm an ACLS instructor and I honestly think that the only reason they didn't eliminate it completely is that they where trying to minimize the number of big changes. I'm guessing it will be gone in the next release.

The big question is whether epi will still be in. When the last guidelines were released, the editorial admitted that epi has shown no benefit in arrest and they only reason that they weren't eliminating it was that there was no double-blind randomized control study!


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## kiwimedic (Dec 28, 2007)

spidermedic said:


> The big question is whether epi will still be in. When the last guidelines were released, the editorial admitted that epi has shown no benefit in arrest and they only reason that they weren't eliminating it was that there was no double-blind randomized control study!



Well now that is interesting, I read the _Circulation_ publication when the 2005 AHA guidelines came out but I didn't remember specificaly seeing that. If I had a choice between being given epi or any other vasoconstrictor or not I'd take it!

We recently eliminated atropine from asystole/PEA and bicarb from all arrests because of the same reason, lack of evidence supporting its use.

It's interesting to me that all after all these years of EMS and medical advancement we can save a trauma victim who has internal bleeding, is hugely hypovalemic and does not reach a trauma center for two hours (which I've seen) but we can't save a guy who has a heart attack two blocks from the hospital.


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## Markhk (Dec 29, 2007)

Our county pulled ET epinephrine but with an additional rationale. 

Apparently the 1:1000 epi was given accidentally IV to patients in anaphylaxis, instead of using 1:10000 epi. So the county decided to pull 1:1000 epi vials from the medics and made IV epi for anaphylaxis a base hospital order.


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## Ridryder911 (Dec 29, 2007)

spidermedic said:


> The big question is whether epi will still be in. When the last guidelines were released, the editorial admitted that epi has shown no benefit in arrest and they only reason that they weren't eliminating it was that there was no double-blind randomized control study!



I too have never heard of that, in fact quite the opposite, other than high dose epi is not beneficial. I am very active in the ECC and AHA National ACLS Task Force, studies do show promising changes with Vasopressin, however; the dosage may have to be modified. 

Here is some current discussions as well from the 12/07 Scientific Studies of ECC and AHA concurrents scientific studies. 

http://www.heart.org/presenter.jhtml?identifier=3051667

R/r 911


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## MasterIntubator (Jan 6, 2008)

We played with ET drugs for many years, and never really gave the chasers, nor the 2.5 mgs either.  Very few good reactions, many unknowns.  In the burn units surfactant can be shoved down the ET tube, up to 100mls or so, which is freaking mind boggling.  
Other thoughts that has come out of our study groups were the drugs pH and effects on the lung lining.

The only great effect I have ever used epi for down the ET, was an asthmatic who shut down with near zero compliance, a shot of epi down the tube gave us better compliance within a minute or two.  

We have down played it, but it is still an option when things fail.


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## spidermedic (Jan 7, 2008)

Here's the statement I'm referring to. It's taken from 
Circulation, Volume 112, Issue 24 Supplement; December 13, 2005

Here's another interesting article that shows high serum epi levels can stimulate coronary thrombosis. It's a dog study, but interesting nonetheless. Certainly something to think about when you're going to push epi in the guy who just coded while shovelling his driveway!

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*Vasopressors, Antiarrhythmics, and Sequence of Actions During Treatment of Cardiac Arrest*
Despite the widespread use of epinephrine and several studies of vasopressin, no placebo-controlled study has shown that any medication or vasopressor given routinely at any stage during human cardiac arrest increases rate of survival to hospital discharge. Most out-of-hospital studies, however, are hampered by heterogeneous populations with prolonged arrest times, making it difficult to identify potentially successful therapies.

A meta-analysis of 5 randomized out-of-hospital trials showed no significant differences between vasopressin and epinephrine for return of spontaneous circulation, death within 24 hours, or death before hospital discharge. A proposal to remove all recommendations for vasopressors was considered but not approved in the absence of a placebo versus vasopressor trial and the presence of laboratory evidence documenting the beneficial physiologic effects of vasopressors on hemodynamics and short-term survival.


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## Porky1 (Jan 7, 2008)

*Epi down the tube*

I have pushed epi, atropine down the tube but honestly can't say I saw any results. I only did it because we couldn't find an IV anywhere and didn't have an IO option. I always cringe at how much fluid I would push considering that most of my cardiac arrest already have some mild to moderate pulmonary edema so I am not helping anything. I can see why the AHA is fazing this option out.


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## jbmedca (Jan 7, 2008)

*Dead is Dead*

Down the tube or IV, I concurr with the study cited above.  Most OOH arrests have extended down times.  Therefore dead is dead.  As one of my teachers once said, "You can't make 'em any dead'er you can only make 'em better." -_-


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## Ridryder911 (Jan 7, 2008)

spidermedic said:


> Here's the statement I'm referring to. It's taken from
> Circulation, Volume 112, Issue 24 Supplement; December 13, 2005
> 
> Here's another interesting article that shows high serum epi levels can stimulate coronary thrombosis. It's a dog study, but interesting nonetheless. Certainly something to think about when you're going to push epi in the guy who just coded while shovelling his driveway!
> ...



One has to be careful reading studies and understand that it was in comparrison of just medication(s) alone with the old standards of CPR and reduction of ATP build up. 

The same study also revealed...._...."There was *no* evidence that routine administration of *any* antiarrhythmic drug during human cardiac arrest increased rate of survival to hospital discharge. One antiarrhythmic, amiodarone, improved short-term outcome (ie, survival to hospital admission) but *did not* improve survival to hospital discharge when compared with placebo41 and lidocaine."_.......... 

The same study describes that *NO* medication actually increases outcome in cardiac arrest... as well as CPR alone without medication does not increase cardiac arrest.. hmmm confusing? 

How about this in regards to neonate and pediatric resuscitation, within the same article:
_..."There was inadequate data to indicate the superiority of room air to 100% oxygen for resuscitation"....._ 

So basically there is *no* proof that oxygen increases survivability?.. 

Does this mean we no longer use it or no longer give medications or specific medications to cardiac arrest? or maybe we should we even do anything, since the likelihood they are going to die anyway? 

As I have described before any procedure or medication only as successful only <10% to 6% + outcome (dependent upon setting) we would never perform it or use it... however; at this time there is no other option unless one wants only a 100% mortality rate. 

Studies are an integral part of medicine, and one definitely should read and be abreast of new and ever changing ideas and different modalities. One also need to understand and read scientific studies as in the (_p_) population, the variables, type of research, and sponsorship of such studies... It can be confusing. 

Good points though...

R/r 911


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## spidermedic (Jan 8, 2008)

Ridryder911 said:


> How about this in regards to neonate and pediatric resuscitation, within the same article:
> _..."There was inadequate data to indicate the superiority of room air to 100% oxygen for resuscitation"....._
> 
> So basically there is *no* proof that oxygen increases survivability?..



Interesting isn't it? There is a theory that a rapid influx of O2 in an arrest patient somehow triggers apoptosis. There's a doc (in Michigan or Minnesota I believe) that has allegedly demonstrated this in animal models and, also allegedly, demonstrated better cardiac arrest outcomes (again, in animal models).  As I recall he's still a couple of years away from human studies.  I have also read that some of the Europeans are already doing room air resuscitation.



Ridryder911 said:


> Does this mean we no longer use it or no longer give medications or specific medications to cardiac arrest? or maybe we should we even do anything, since the likelihood they are going to die anyway?



Good question. My position is that we shouldn't be doing things that obviously don't work as it takes us away from doing the things that do or might work.  We really gotta ask ourselves whether what we're doing makes the patient better or  are we  doing it out of habit or because it  makes  us feel like we're at least doing _something_. Atropine in asystole anyone? 



Ridryder911 said:


> As I have described before any procedure or medication only as successful only <10% to 6% + outcome (dependent upon setting) we would never perform it or use it... however; at this time there is no other option unless one wants only a 100% mortality rate.



At 6-10% you're below the level of the placebo effect. Not to be flip, but you could essentially inject urine and get a similar success rate.

It's  like the old saying "insanity is doing the same thing over and over and expecting different results"  It's time to get away from the things we're comfortable with but don't work (such as epi) and look at new modalities.  We've got hospitals and EMS services that are pushing epi by the gallon but dig in their heels about using an ITD (class IIa) which is actually supported by science. It just doesn't make sense to me.

Interesting conversation!

Sacred cows slaughtered, while you wait!


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## CAMedicJohn (Jan 20, 2008)

*We don't do it anymore...*

We got the EZ-IO this past year and in the same protocol update the county removed the tube administration route. 
Now 2 sticks, then straight to the drill...
:wacko::wacko::wacko:


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## Rangat (Jan 20, 2008)

CAMedicJohn said:


> We got the EZ-IO this past year and in the same protocol update the county removed the tube administration route.
> Now 2 sticks, then straight to the drill...
> :wacko::wacko::wacko:



Jugular? Femoral?


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## Anomalous (Jan 21, 2008)

CAMedicJohn said:


> :wacko::wacko::wacko:



You gotta love the 'triple whacko smiley'


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## CAMedicJohn (Jan 22, 2008)

EJ if it is available of course... Femoral ? I am looking for veinous not arterial access.. We are not allowed to access arterial lines in field.
:wacko::wacko::wacko:


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## triemal04 (Jan 22, 2008)

CAMedicJohn said:


> EJ if it is available of course... Femoral ? I am looking for veinous not arterial access.. We are not allowed to access arterial lines in field.
> :wacko::wacko::wacko:


Thank you.  You have just demonstrated how EMS education is lacking in the US.  Beautiful post.


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## CAMedicJohn (Jan 22, 2008)

I am glad to oblige.. I was under the impression that Femoral vein or arterial access is considered central not peripheral. 

When are you allowed to do a central line in the field outside of a sterile environment?
:wacko::wacko::wacko:


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## Markhk (Jan 22, 2008)

Can we all agree that we are just happy we have moved beyond the "adrenaline to the heart" stage of EMS?


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## Flight-LP (Jan 22, 2008)

Rangat said:


> Jugular? Femoral?



Unfortunately, you are starting to see the differences in education and training amongst various country's. The U.S. has, in general, removed central venous access from protocols as the EZ-IO is quick, efficient, and relatively simplistic. As an advanced provider who has done my fair share of femoral and subclavian lines, I have to say I do prefer the I/O because of the aformentioned attributes. If I am having to consider an I/O or central access, then there is a critical need for that access. Therefore, I want it fast, reliable, and with minimal complication. The EZ-IO wins in all catagories.

Not to mention the times I have seen Paramedics "accidentally" obtain a blood gas 'cause they hit the wrong vessel!

Back to the original subject..........

Drugs down tube bad!


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## Ridryder911 (Jan 22, 2008)

CAMedicJohn said:


> I am glad to oblige.. I was under the impression that Femoral vein or arterial access is considered central not peripheral.
> 
> When are you allowed to do a central line in the field outside of a sterile environment?
> :wacko::wacko::wacko:



Actually, I have been performing central lines since about 1988 in the field setting. In fact, Seattle performed them since 1978... Personally, never seen arterial lines nor any reason for such except monitoring. Yes, we used to do intracardiac Epi until the 80's. Pretty simple, if it not work, the code was basically over. 

Now, with the easy I/O the need to establish central lines has decreased remarkably. 

R/r 911


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## tydek07 (Mar 14, 2008)

I have not given drugs down an ETT myself. But from what I have been told/heard, is that it is usually your last effort and does not do much. I know that in the past, medics use to be able to give multiple drugs down the tube, and now-a-days services are slowely decreasing the number of drugs allowed down the ETT. 

*If you cannot get an IV during VF, you can usually get an IO*. Since the "big bang" of IO use, the drugs down the ETT are becoming obsolete.


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