Cardiovascular Critical Care II
Medication background (rhythm independent considerations)
Goal: Increase myocardial blood flow during CPR and help achieve ROSC
ii.
Drug delivery
| (a) | Central intravenous administration is recommended, if available. Central line placement |
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should not interrupt CPR. The advantage of central administration is higher peak
| (b) | If peripheral administration of medications is necessitated, a bolus injection should be |
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followed by a 20-mL bolus of an intravenous fluid (e.g., 0.9% sodium chloride) to facilitate
| (c) | If proximal humerus intraosseous (IO) access is used, administration and drug delivery |
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are similar to central venous access. If proximal or distal tibial intraosseous access is
used, administration and drug delivery are similar to peripheral venous access and would
necessitate a 20-mL bolus or pressure bag to facilitate drug administration. In a randomized
cadaver study, tibial IO access has been shown to be easier to obtain, which allows for
faster medication administration (Medicine 2016; 95: e3724). Data analyses suggest that
intraosseous access is associated with poorer OHCA survival and fewer favorable neurologic
96). Intraosseous access may have initially been selected by first responders because of
perceived complexity and influential patient characteristics. However, additional analysis
has found that tibial intraosseous access compared with intravenous access is associated
with a lower likelihood of ROSC and survival to hospitalization (Resuscitation 2017;117:91-
6). The most recent guidelines now support the use of intravenous access preferentially
unless it cannot be obtained (Circulation 2020;142:S366-S468). In these circumstances,
intraosseous access is reasonable.
| (d) | Endotracheal (ET) delivery |
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| (1) | NAVEL acronym summarizes medications that have been studied and shown to have |
tracheal absorption by ET tube delivery. N – naloxone, A – atropine, V – vasopressin,
E – epinephrine, L – lidocaine.
| (2) | Serum concentrations of medications are lower when given by ET delivery. |
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| (3) | Optimal ET doses unknown; typically, they are 2–2.5 times intravenous doses but may |
| (4) | Should be diluted with either 5–10 mL of 0.9% sodium chloride or sterile water and |
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injected directly into the ET tube, ideally during pulse check to avoid medication
| (e) | Peak effect of intravenous or intraosseous medication delayed 1–2 minutes during CPR. |
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| (f) | Theoretical concern that giving high-dose bolus vasopressors after ROSC following |
defibrillation may precipitate cardiac instability and re-arrest. May be avoided by using
physiological monitoring such as quantitative waveform capnography, intra-arterial
pressure monitoring, or continuous central venous oxygen saturation monitoring and
avoiding administration of vasopressors if ROSC occurs (J Emerg Med 2009;38:614-21;