Alternative routes for drug delivery

Intraosseous route
If intravenous access cannot be established, intraosseous delivery of resuscitation drugs will achieve adequate plasma concentrations. Several studies indicate that intraosseous access is safe and effective for fluid resuscitation, drug delivery and laboratory evaluation. Traditionally, the intraosseous route is used mainly for children, but it is also effective in adults.

Drugs given via the tracheal tube
Resuscitation drugs can also be given via the tracheal tube, but the plasma concentrations achieved using this route are variable and substantially lower than those achieved by the intravenous or intraosseous routes.
Doses of adrenaline 3—10 times higher than when given intravenously are required to achieve similar plasma concentrations.79,80 During CPR, lung perfusion is only 10—30% of the normal value, resulting in a pulmonary adrenaline depot. When cardiac output is restored after a high dose of endobronchial adrenaline, prolonged reabsorption of adrenaline from the lungs into the pulmonary circulation may occur, causing arterial hypertension, malignant arrhythmias and recurrence of VF.
Lidocaine and atropine can also be given via a tracheal tube, but the plasma concentrations achieved are also variable. If intravenous access is delayed or cannot be achieved, consider obtaining intraosseous access. Give drugs via the tracheal tube if intravascular (intravenous or intraosseous) access is delayed or cannot be achieved. There are no benefits from endobronchial injection compared with injection of the drug directly into the tracheal tube. Dilution with water instead of 0.9% saline may achieve better drug absorption and cause less reduction in PaO2.

European Resuscitation Council Guidelines for Resuscitation 2005
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