We may not have all been there, but for those of have, it’s honestly amazing to be able to say “oh, just toss this medication down the tube.” Today, I wanted to bring to light using the endotracheal tube for medication administration during ACLS resuscitative measures. 

The inspiration for this was recently finding myself at my first PALS certification and, being the pharmacist in the room, suggesting doses for endotracheal administration during our simulation scenarios. The rest of the room looked puzzled to hear about this information, so it turned into a really great teaching point. 
First: When is it appropriate to administer meds through the ET tube?
The obvious first assumption to be made is that the patient is endotracheally intubated. The next box on the checklist is that no other access will be quickly obtainable. In my particular instance in the past, IV access was extremely difficult due to volume depletion, and there was a significant delay in obtaining an IO drill. If you anticipate these difficulties in getting vascular access, ET tube administration may be appropriate.

Second: What medications can be administered through the ET tube?
When I teach people, I tell them, “Pretend like it’s somebody who is talking to you about something they know nothing about as if they’re an expert – they need to stay in their LANE.” LANE stands for lidocaine, atropine, naloxone, and epinephrine. These are the four meds that have been shown to absorb through the alveoli. If you’re considering using any other meds in the ACLS protocol through the ET tube, they are not studied/don’t absorb, so try to stay in your LANE.

Third: What doses of these medications are used?
For ET tube administration, it’s a tertiary option for a reason. Alveoli are okay at absorbing meds, but it is far from optimal. For adults, a good rule of thumb is to just double the dose. For example, with atropine give 2mg through the ET tube, epinephrine give 2mg, and lidocaine give 3mg/kg. Naloxone remains 2mg at a time for all sources that I can find.
For pediatric patients, we adjust a little differently. Atropine is increased from 0.02mg/kg IV to 0.03mg for the ET tube (though it is not addressed, I would still use a minimum dosage of 0.1mg). Epinephrine is also different. Instead of a two-fold increase, epinephrine receives a TEN-fold increase in pediatric arrests, from 0.01mg/kg IV to 0.1mg/kg for the tube. There is no maximum dose suggested for pediatric patients. However, if I was in a code situation making recommendations, I would personally cap the dose at the adult dose, but this is such an under-studied area that information is extremely limited. Lidocaine remains at 3.0mg/kg for ET tube administration and naloxone remains as 0.1mg/kg (max of 2mg) for the tube per PALS guidelines.

Fourth/Last: Other points
For ET tube administration, meds are generally prepared/administered in 5-10mL solutions in adults. The atropine emergency syringes (typically 1mg/10mL) can be given undiluted. Naloxone in emergency syringes is usually 2mg/2mL, so it should be flushed with at least 5mL after administration. Lidocaine emergency syringes are 100mg/5mL, so usually can be given without a flush. Epinephrine gets a little tricky – guidelines recommend diluting 2 x 1mg/1mL ampules with 5-10mL of saline and administering it that way. The 1mg/10mL syringes may just be too much volume and too diluted for the alveoli to absorb optimally.
In pediatric patients, it would be wise to dilute most medications to a target of 5-10mL. Just remember, if it’s not already 5-10mL and you can’t MAKE it 5-10mL, give it undiluted and flush it afterwards with 5-10mL.​​​​​​​
Also, stay in your LANE. Now, go save some lives!
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